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Navmed P-SOSl 
Volume 1 

United States 
Government Printing Office 
Washington, 1953 





Navmed P.5031 
Volume 1 

Franklin Delano Roosevelt, President of the United States, 1933 to 1945. 


The achievements of military medicine 
in World War II were numerous and re- 
markable, and the results equally re- 
markable. Out of every 100 wounded men 
98 recovered, in contrast with the experi- 
ence in World War I, when only about 
90 recovered out of every 100 wounded 
men. In earlier wars, one-half or more 
of all wounded men died as a result of 
their injuries. The World War II recov- 
ery rate for some injuries was striking; 
as an example, deaths from wounds of 
the head, chest, and abdomen were about 
65 percent lower than in World War I 

The chief reason why so many more 
lives were saved in World War II was 
the high standard of professional skill 
and training of the physician, dentist, 
nurse, and corpsman. Further, skilled 
medical personnel were assigned to ships, 
planes, and amphibious forces in all parts 
of the world, and vast quantities of medi- 
cal supplies — drugs, serums, plasma, 
whole blood, beds, bedding, and hospital 
equipment and appliances — were pro- 
vided for every operating force no mat- 
ter where located. 

Although the war officially began for 
the United States on 7 December 1941, 
the conflagration in Europe in the fall of 
1939 was a portent and preparations were 
then made to meet the approaching na- 
tional danger. These included a vast ex- 
pansion of the Navy and its Medical De- 
partment. At the beginning of the war 

the Medical Department of the Navy 
consisted of less than 13,000 persons ; in 
1945, at the peak of expansion, it included 

169,225 men and women. To obtain the 
medical facilities and supplies necessary 
for this expansion w^as a task of great 

Many new hospitals were built, and 
suitable buildings and grounds were ac- 
quired and converted to special hospitals. 
Overseas, the mobile hospital was an in- 
novation that proved of immense value. 
Hospital transports were of great im- 
portance in the campaigns in the Central 
and Western Pacific. Hospital ships were 
an invaluable asset, not only in furnish- 
ing hospitalization for personnel in fleet 
and amphibious forces, but also in acting 
as floating medical warehouses for the 
distribution of medical supplies, serums, 
plasma, and whole blood. The use of some 
types of landing craft as hospitals and 
for the collection of casualties during am- 
phibious landings was also a most im- 
portant development. 

The procurement of drugs, vaccines, 
serums, surgical dressings and instru- 
ments, and hospital equipment and ap- 
pliances of every type was a vast under- 
takino- which was well done, but the 
prompt and efficient distribution of these 
supplies to the Navy in every part of the 
world was the really great achievement 

The prevention of disease was as im- 
portant as the care of the sick and 


wounded; personnel were vaccinated 
against such diseases as smallpox, ty- 
phoid fever, typhus fever, tetanus, yellow 
fever, and cholera. This resulted in the 
saving of countless lives and prevented 
the disastrous effects of epidemic disease 
in the combat forces. The measures insti- 
tuted for the prevention of malaria, 
typhus fever, and other diseases were 
guides to the success of many campaigns. 

Dental officers and dental personnel 
played an important part in the war. They 
gave first aid to the wounded and ren- 
dered the finest dental care. Mobile den- 
tal units were built to care for personnel 
attached to isolated stations where regu- 
lar dental service could not be main- 
tained. A program of prosthetic dentistry 
was developed which saved valuable man- 
power for the Navy. Working with the 
plastic surgeon, the dental officers de- 
vised prosthetic facilities for oral, facial, 
and eye wounds that facilitated the re- 
pair of these serious and disfiguring in- 
juries and hastened the rehabilitation of 
the injured or blinded man. 

This war emphasized the great impor- 
tance of the specialities of aviation medi- 
cine, submarine medicine, and amphib- 
ious medicine. The latter was so com- 
pletely organized that medical assistance 
was brought to the wounded men on the 
beachhead or in the field at the very 
earliest moment; never before had it 
been possible to bring first aid to men on 
the field of battle so early. 

The Hospital Corps of the Navy 
played a great and heroic part in this as 
in every other war since its establish- 
ment in 1898. Everywhere they were con- 
spicuous for their courage and devotion 
to duty. The lives of many men were 

saved by their fearlessness and by the 
skillful care they rendered. 

The splendid work done by the Navy 
Nurse Corps in World War I was re- 
peated in World War 11. In hospitals at 
advance bases and in hospital ships and 
hospitals all over the world they carried 
out their mission tirelessly and effi- 
ciently. Their effect on morale, and the 
comfort and assistance they rendered to 
the sick was invaluable. The Women Ap- 
pointed for Volunteer Emergency Serv- 
ice, newly organized in World War II, 
rendered the finest assistance to the 
Medical Department in the special fields 
allied to medidne, . 

Developments in medicine and surgery 
and their application to military medical 
problems made necessary a program of 
continuous research. The newly estab- 
lished Naval Medical Research Institute 
at Bethesda, Md., formed the center of 
this work in the field of naval military 
medicine. Here, as well as at other naval 
medical activities, workers in the sciences 
allied to medicine, the physiologist, psy- 
chologist, physicist, chemist, bacteriol- 
ogist, botanist, and entomologist (added 
to the family of the Medical Department 
during World War II), carried on re- 
search problems, and their work con- 
tributed to the prevention of disease, the 
relief of suffering, and the saving of 

As the wartime Surgeon General of 
the Navy, I am proud to have directed 
the Medical Department in its great 
tasks. I also had the honor to serve as 
White House physician. This made my 
work greater, for frequently I was away 
from Washington on the various long 
journeys made by President Roosevelt to 


attend conferences or inspect military 
forces in the field. These travels, how- 
ever, gave me a great advantage, for they 

enabled me to visit almost all theaters of 
war and to observe the needs and problems 
of the medical activities in the field. 

The great responsibilities imposed 
upon the Medical Department of the 
Navy by the war were discharged so 
efficiently because of the skill, the cour- 
age, and the unswerving devotion to duty 
of all members of the Medical Depart- 
ment, from the hospital apprentice to the 

personnel of the office of the Sm-geon 
General. Their magnificent achievements 
in medicine during World War II were 

unprecedented and were symbolized by 
President Roosevelt at the dedication 
ceremonies of the National Naval Medi- 
cal Center where he said: "Let the hos- 
pital stand for all men to see through all 
the years as a monument to our deter- 
mination to work and to fight until the 
time comes when the human race shall 
have that true health in body and spirit 
which can be realized only in a climate 
of equity and faith." 


Vice Admiral (MC) USN (Retiredy 

* Surgeon General, U. S. Navy, 1938-46. and Physician to the White House, 193&-45. 



Early in World War II, President 
Roosevelt directed the "preserving for 
those who come after us an accurate and 
objective account of our present experi- 
ence," and on 23 March 1942 a "Commit- 
tee on Records of World War IF' was 
designated to activate such a program. 
In the Navy, Surgeon General Mclntire 
ordered the medical departments of all 
ships and stations to include in their 
Annual Sanitary Report an account of 
their experiences in administrative mat- 
ters as well as in clinical and preventive 
medicine. These reports covered the 
period from 7 December 1941 to 31 
August 1945. 

In 1943 an Administrative History Sec- 
tion was designated in the Administra- 
tive Division of the Bureau. This group 
assembled a Historical Data Series from 
the Annual Sanitary Reports and, under 
the general rules prescribed by the Direc- 
tor of Naval History, compiled the "U.S. 
Navy Medical Department Administra- 
tive History 1941-1945." 

The data for chapters I and II were 
obtained from the sources mentioned. 
The remaining chapters were written, 
individually or in collaboration, by 37 
naval officers, each recording the accom- 
plishments of the Medical Department of 
the Navy in the field with which, by 
virtue of wartime experience, he was 
peculiarly famifiar. The Aviation Branch 
of the Research Division of the Bureau 

compiled the section of Chapter X on 
Naval Aviation Medical Research. 

The original work of assembling and 
editing this material was accomplished 
by Capt. Louis H. Roddis (MC) USN 
(Retired), who acted as editor until 30 
June 1950. At that time Capt. Joseph L. 
Schwartz (MC) USN took over the task 
and completed a major part of it before 
his retirement on 7 August 1951. 

This history is not an exhaustive re- 
port, but merely highlights the successful 
manner in which the 169,225 officers and 
men of the Medical Department coped 
with unprecedented problems in clinical 
and preventive medicine and in medical 
administration during the war. New hos- 
pital facilities were required to fit a new 
type of warfare, and the transportable, 
self-contained hospital was devised. New 
types of vehicles for medical care and 
transportation of patients were needed, 
and the jeep ambulance, the amphibious 
surgical unit, the hospital-type LST, and 
the ambulance plane were developed. 
Penicillin, whole blood, and plasma were 
made available in every battle zone. When 
necessary, blood was flown directly from 
the United States to the combat area. 
During the battle of Two Jima, whole 
blood was dropped by parachute to med- 
ical units in action in the field 48 hours 
after the plane had taken off from San 
Francisco. For the first time in military 
history, teams of epidemiologists accom- 


panied assault forces, and field sanitation, 
hygiene, and preventive medicine were 
immediately instituted. These teams were 
a vital factor in lowering the morbidity 
and mortality rates in combat troops. 

Officers of the Medical, Dental, Nurse, 
and Hospital Corps, specialists in fields 
allied to medicine, WAVES, and Hospital 

Corpsmen brought to the patient the 
best in clinical medicine. By their abil- 
ity, resourcefulness, and devotion, they 
achieved results never before attained in 
military medicine. Volume I of The 
History of the Medical Department of the 
U. S. Navy in World War H is a partial 
record of their accomplishments and a 
testimony to their capable performance. 

Captain (MC) USN, Editor 


Table of Contents 

— ' Page 



. . VIII 






Chapter I. Facilities of the Medical Department of the Navy 1 

Continental and Extracontinental Hospitals 

Development of Mobile and Base Hospitals 

Special Augmented Hospitals 

Medical Facilities; European, Atlantic and African Theaters 

.... Submarine Medicine ^ 

The Dental Situation 

II. Experiences in Battle of the Medical Department of the Navy 63 

Pearl Harbor gg 

The Solomons Campaign 


New Georgia 


, New Hebrides g^ 

Saipan gg 

Iwo Jima 


Medical Action Afloat 

Prisoners of War and Enemy Civilians 



Salerno ^og 

. Dental Officers' Experiences in Battle 


III. Mobile and Base Hospitals ^^g 

Lions and Cubs * 

U. S. Naval Base Hospital No. 12 


IV. Medical Procurement and Supply 

Advanced Base Program 

Extracontinental Medical Supply Storehouses (MSS s) 

Medical Supply From Floating Outlets 

Advanced Base Supply ^^g 

Marine Combat Supply 

Whole Blood for Transfusion 

Materiel Shortages and Defects 

V. Development of Medical Services for Marine Corps Forces in the Field ... 161 




VI, Medical Service With Amphibious Forces in the Saipan Operation 171 

VII. Medical Service in the Seventh Amphibious Force 183 

VIII. Medical Aspects of Naval Operations in the Mediterranean 189 

Organization of the Naval Medical Department 189 

The Naval Medical Corps in Amphibious Operations 191 

Medical and Epidemiological Considerations 193 

IX. Air Evacuation and Transportation of Sick and Wounded 203 

X. Aviation Medicine 209 

A. Developments in Aviation Medicine 209 

B. High Altitude Training 212 

C. Night Vision Training 218 

D. Aviation Psycholoi>:y 221 

E. Naval Aviation Medical Research 228 

XL Burns 243 

XII. Program for the Deaf 245 

XIII. Blindness 249 

XIV. Neurosurgery 253 

XV. Peripheral Neurosurgery 261 

XVI. Thoracic Injuries 267 

XVIL Orthopedic Casualties Aboard a Hospital Ship 283 

XVIII. Cardiology 287 

XIX. Dermatology 299 

XX. Medical Research 315 

XXL Clinical Psychology in the Screening Program 321 

XXII. Medical Aspects of Blast 329 

XXIII. Roentgenology 347 

XXIV. Rehabilitation 357 

XXV. Malnutrition in Repatriated Prisoners of War 367 



Frontispieces : 

Franklin Delano Roosevelt, President of the United States, 1933 to 1945. 

Ross T Mclntire, Vice Admiral (MC) USN (Retired), Surgeon General, United States 

Navy, 1938 to 1946. 

Figure Page 

1. U. S. Naval Hospital, Annapolis, Md ^ 

2. U. S. Naval Hospital, Bremerton, Wash ^ 

3. U. S. Naval Hospital, Brooklyn, N. Y f 

4. U. S. Naval Hospital, Charleston, S. C 

5. U. S. Naval Hospital, Chelsea, Mass ^ 

6. U. S. Naval Hospital, Corona, Calif ^ 

7. U. S. Naval Hospital, Corpus Christi, Tex 5 

8. U. S. Naval Hospital, Great Lakes, 111. . 7 . t . d 

9. U. S. Naval Hospital, Jacksonville, Fla 6 

10. U. S. Naval Hospital, Mare Island, Calif 6 

11. U. S. Naval Hospital, Newport, R. I 

12. U. S. Naval Hospital, Parris Island, S. C 7 

13. U. S. Naval Hospital, Pensacola, Fla ^ 

14. U. S. Naval Hospital, Philadelphia, Pa ^ 

15. U. S. Naval Hospital, Portsmouth, Va. 9 

16. U. S. Naval Hospital, Portsmouth, N. H. 1^ 

17. U. S. Naval Hospital, Quantico, Va 1^ 

18. U. S. Naval Hospital, San Diego, Calif 1^ 

19. U. S. Naval Hospital, Washington, D.C 1^ 

20. U.S.S. Relief 

21. U.S.S. Solace ■ ■ 

22. Average patient census, all naval hospitals 1^ 

23. U. S. Naval Hospital, Bethesda, Md 14 

24. U. S. Naval Hospital, San Francisco (Treasure Island), Calif 14 

25. U. S. Naval Hospital, Oakland, Calif 1^ 

26. U. S. Naval Hospital, Seattle, Wash 1^ 

27. U. S. Naval Hospital, Key West, Fla 1^ 

28. U. S. Naval Hospital, Long Beach, Calif 1^ 

29. U. S. Naval Hospital, Norfolk, Va l'^ 

30. U. S. Naval Hospital, Norman, Okla 1'^ 

31. Mobile Hospital No. 1 at Guantanamo Bay, Cuba IS 

32. Mobile Hospital No. 1 at Bermuda 

33. U. S. Naval Hospitals in the Pacific in 1942 20 

34. Mobile Hospital No. 8 at Guadalcanal 21 

35. U. S. Naval Convalescent Hospital, Harriman, N.Y 22 

36. U. S. Naval Hospital, Farragut, Idaho 23 


Figure Page 

37. U. S. Naval Hospital, Bainbridge, Md 23 

38. ' U. S. Naval Hospital, St. Albans, N.Y 24 

39. U. S. Naval Hospital, Memphis, Tenn 24 

40. U. S. Naval Hospital, Sampson, N. Y 25 

41. U. S. Naval Hospital, New Orleans, La 25 

42. U. S. Naval Hospital, Camp Lejeune, New River, N. C 26 

43. U. S. Naval Hospital, Santa Margarita Ranch, Oceanside, Calif 26 

44. U. S. Naval Hospital, Shoemaker, Calif 27 

45. U. S. Naval Base Hospital No. 4, Wellington, New Zealand ^ . . . 27 

46. U. S. Naval Convalescent Hospital, Yosemite, Calif 28 

47. U. S. Naval Convalescent Hospital, Glenwood Springs, Colo 28 

48. Mobile and base hospitals in the Pacific in 1944 29 

49. U. S. Naval Hospital, San Leandro, Calif 30 

50. U. S. Naval Hospital, Fort Eustice, Va 31 

51. U.S.S. Samaritan 31 

52. U. S. Naval Hospital, Dublin, Ga 32 

53. U. S. Naval Hospital, Corvallis, Oreg 32 

54. U.S.S. Consolation 33 

55. U.S.S. Haven 33 

56. U.S.S. Rescue 34 

7. U.S.S. Tranquillity 34 

58. Main Ward Buildings, Base Hospital No. 4, Wellington, New Zealand 35 

59. One of the wards. Base Hospital No. 4 36 

60. Laundry, Base Hospital No. 6, Espiritu Santo, New Hebrides 36 

61. Naval hospitals and dispensaries in the European Theater 39 

62. Naval hospitals and dispensaries in the North and South Atlantic Theaters ... 40 

63. Naval hospitals and dispensaries in North Africa 41 

64. Minor surgery aboard a submarine 44 

65. Medical locker in a submarine 44 

66. 67, and 68. Disaster at Pearl Harbor 63, 64 

69. Patients being treated for shock aboard the U.S.S. Solace 65 

70. Survivors after rescue at sea — sickbay of PCE (R) 851 66 

71. Sickbay on Guadalcanal 67 

72. First aid for wounded marines at a frontline battle dressing station in the 

Solomons 68 

73. Collecting the wounded 68 

74. Continuing first aid during transportation by jeep 69 

75. Carrying wounded aboard a landing boat for further transportation to an APA or 

hospital ship 69 

76. Transfusion of wounded immediately upon arrival aboard a landing craft 70 

77. Litter carry of wounded on Guadalcanal 70 

78. Air transportation of the wounded 71 

79. Evacuation of casualties by air 72 

80. Natives under supervision of Malaria Control Unit personnel oiling the pools on 

Munda, New Georgia 77 

81. Evacuation of casualties in an LST 78 

82. First aid in a foxhole in the jungle at Empress Augusta Bay 79 

83. Transportation of dead and wounded via amphibious tractor from the front lines 

on Bougainville 79 


Figure Page 

84. Bomb shelter below sickbay on Bougainville 80 

85. Malaria Control Unit in action in the jungle 81 

86. Mobile Malaria Control Unit in action 81 

87. Supply yard of Malaria Control Unit on Espiritu Santo 82 , 

88. Malaria control on Espiritu Santo •.• 82 j 

89. First-aid station being set up on the beach at Saipan 84J 

90. Blood and plasma transfusions on the beach at Saipan . . V . 841 

91. Transporting the wounded in a rubber boat ' - . . . , , ... .1 85 1 

92. Second Marine Division Hospital in a captured Jap radio station 85l 

93. Emergency surgery in a hospital on Saipan 86^ 

94. Modern diagnostic procedures on a battlefield on Saipan 87 

95. U. S. Marines pay final tribute to their buddies in the Solomons 88 j 

96. Bodies of Marines of the Third Division awaiting burial ^ 88 I 

97. One of the most important phases of military medicine was the rapid distribution of 

whole blood to every fighting front 90 

98. Landing medical supplies on Blue Beach at Iwo Jima 91 

99. Administering blood plasma in a foxhole on the invasion beach at Iwo Jima .... 92 

100. First aid on the invasion beach at Iwo Jima 93 

101. First aid and physical assistance to the wounded on Iwo Jima ^ 93, 

102. A wounded marine brought to the beach by jeep ambulance from the fighting front 

on Iwo Jima 94 

103. Marine stretcher bearers carrying the wounded into a foxhole for first aid 95 

104. Corpsmen bringing the wounded from the front lines to evacuation ships on the 

beach . - - 95 

105. Surgical care in an abandoned Jap dugout 96 

106. Administering intravenous fluids in an abandoned Jap dugout 97 

107. Hoisting a patient aboard the U.S.S. Solace 99 

108. Transferring patients from an LCV to Hospital Ship H.M.S. Lancaster 100 

109. The U.S.S. Samaritan anchored off Okinawa. Transferring a patient from a small 

boat via an elevator rigged over the side of the ship 101 

110. Refrigerator units for the storage of blood plasma and vaccine sera 102 

111. Portable electric refrigerator for storage of biologicals, blood, and plasma 103 

112. Hospital tent on an Iwo Jima airfield 105 

113. Advanced hospital at Koza, Okinawa 105 

114. A mobile operating room directly behind the front lines on Okinawa 107 

115. Hangar deck, U.S.S. Bunker Hill ... 108 

116. The bush master. An amphibious tractor equipped as a mobile amphibious operating 

room 1^9 

117. The bush master's operating room in use 110 

118. Transferring the wounded men from amphibious tractor to a landing barge Ill 

119. Evacuating casualties from the front lines by a cub plane Ill 

120. Cub plane taking off from the road-runway with a Marine casualty on board 112 

121. Injured man receiving treatment aboard plane 112 

122. Wounded aboard a transport plane being evacuated to a hospital 113 

123. First aid aboard U.S.S. Nevada after Jap **kamikaze'' attack 114 

124. U.S.S. Franklin after ''kamikaze'' attack — patients being transferred to U.S.S. 

Santa Fe 115 

125. First aid to Filipino mother and her child on the invasion beach at Leyte, Philip- 

• f . pine Islands 117 

'. . / '^ ' XIV 

FIGURE ^ p„g^ 

126. Hospital corpsmen with a Marine division on Saipan administering first aid to 

civilians 118 

127. Hospital facilities for enemy civilians were established at the earliest opportunity 118 

128. Sick call for natives in the Solomons 119 

129. Wounded Japanese prisoner of war being carried aboard a V2F for transportation 

to a hospital on Guadalcanal 119 

130. Dental care for a young Majuro 120 

131. Hospital care for natives on Majuro landing 120 

132. LST landing men and supplies on the beach in Southern France 121 

133. Casualties being carried aboard an LST on an invasion beach in France 122 

134. Casualty loading station on a beach in Southern France 123 

135. Bringing the wounded, including German prisoners, to U.S.S. Texas 123 

136. LST showing the demountable brackets 124 

137. Landing supplies on the beach at Salerno, Italy 127 

138. Rendering first aid on the invasion beach 128 

139. A Navy dentist administering dental treatment in one of the typical tent-type 

dental clinics at an advanced base 132 

140. U.S. Naval Mobile Hospital No. 1 ...... _ 133 

141. U.S. Naval Mobile Hospital No. 1 ... 134 

142. Erecting one of the sectional buildings 134 

143. Erecting another of the sectional buildings 135 

144. Aerial view of U.S. Naval Mobile Hospital No. 1 136 

145. Lion One medical department organization 140 

146. Anatomy of a quonset hut; laying the frame 141 

147. Anatomy of a quonset hut ; erecting the ribs 141 

148. Hospital completed 142 

149. Hospital completed in a coconut grove 142 

150. Pharmacy in a quonset hut 143 

151. Officers' quarters 144 

152. U.S. Naval Base Hospital No. 12, Netley, Hants, England 146 

153. Medical supply faeilities, United States and extracontinental 150 

154. One chain of evacuation of the wounded 177 

155. Tabulation of Navy air l)hist experiments 332 

156. Design of Navy air blast experiments on protection afforded by terrain 333 

157. Plan of Navy experiments on air blast, eliminating shell fragments and reflectance 334 

158. Experimental set-up in determination of deterrent blast pressure for divers 

(shallow water) 336 

159. Experimental set-up in determining deterrent blast pressure for divers (deep 

water) 337 

160. Apparatus to determine efficiency of British anti-blast vest 339 

161. Calculated lethal ranges for immersed personnel exposed to underwater explosions . 341 

162. Main x-ray room showing unit secured for sea 348 

163. The original photofluorographic unit constructed at U.S. Naval Medical School . . 350 

164. Stationary photofluorographic unit 351 

165. Mobile photofluorographic unit 352 

166. Floor plan of mobile photofluorographic unit 353 

167. 168. American prisoners of war 367, 368 

169. American prisoners of war in a Japanese hospital 368 

170. Daily food ration for American prisoners of war 369 


Figure Page 

171. Percentage incidence of symptoms of malnutrition in two groups of patients studied 

clinically 372 

172. Percentage incidence of signs of malnutrition in two groups of patients studied 

clinically , 373 

The photograph in figure 3 is by courtesy of the Fairchild Air Photos Co. The remainder 
are official photographs of the U.S. Coast Guard, U.S. Marine Corps, U.S. Navy, U.S. Army, and 
U.S. Air Force. 



Table ^ 


1. Increase in Medical Department personnel on active duty, 1939-45 1 

2. Hospitals and iiospital ships in commission in 1941 1 

3. Hospitals commissioned in 1942 13 

4. Mobile and base hospitals commissioned in 1942 21 

5. Hospitals commissioned in 1943 22 

6. Hospitals and hospital ships commissioned in 1944 30 

7. Hospitals and hospital ships commissioned in 1945 30 

8. Medical supply facilities, all types ; 35 

9. Dispensaries in the United Kin<2:dom 38 

10. Hospitals and dispensaries in the Atlantic Theater 38 

11. Mediciil Department facilities in the African Theater, 1 January 1945 42 

12. Diseases of the urogenital system in submarine personnel on war patrol 48 

13. Incidence per thousand of disease or injury of submarine personnel (1944) 48 

14. Diseases limiting duration of submarine patrols 48 

15. Habitability reports of fleet-type submarines 49 

16. Psychiatric casualties encountered aboard submarines 53 

17. Deaths occurring aboard submarines on war patrols _ 53 

18. Number of men trained and qualified in "lung" escape 56 

19. Dental facilities as of August 1945 57 

20. Number of First Marine Division patients hospitalized for malaria as compared with 

other diseases — Guadalcanal 73 

21. Casualties and evacuation — Iwo Jima 104 

22. Disease conditions requiring evacuation from Okinawa 109 

23. Maxillofacial battle casualties treated in the Solace 129 

24. Statistical report — Second Marine Division hospital 180 

25. Typhus cases and deaths in Naples 197 

26. Types of plague cases seen in Dakar, and percent mortality 199 

27. Methods of treatment of plague cases 200 

28. Results of treatment of plague cases 200 

29. Incidence of decompression illness in low-pressure chamber training flights 217 

30. Blindness, Navy and Marine Corps, World War II 250 

31. Mortality rate from thoracic wounds in wars prior to World War II 267 

32. Cardiovascular diseases observed during early Guadalcanal period 295 

33. Invalided from the service for tuberculosis (all forms) , U. S. Navv and Marine Corps, 

1930-45 / 354 

34. Original admission rates per 1,000 average strength for tuberculosis (all forms), 

according to occupation, U.S. Navy and Marine Corps, 1930-45 354 

35. Tuberculosis (all forms), admission rates, noneffective ratios, and death rates, U. S. 

Navy and Marine Corps, 1930-45 355 

36. Physical condition of repatriated prisoners of war 371 


258015— .53 2 

Chapter I 

Facilities of the Medical Department of the Navy 

Joseph L. Schwartz, Capfain (MC) USN (Retired) 

Continental and Extracontinental Hospitals 

Long before the attack on Pearl Harbor, the 
75 officers, 32 enlisted men, and 225 civilians 
who manned the 11^ divisions of the Bureau 
of Medicine and Surgery under the direction 
of the Surgeon General, Rear Admiral Ross 
T Mclntire (MC) USN, were busily engaged 
with plans and problems involved in processing 
personnel, expanding physical and material 
facilities, and stockpiling supplies for the Med- 
ical Department of the Navy to meet the 
needs of war, should it involve the United 
States. The war already sweeping over Europe 
had brought forth in 1940 the declaration by 
P]'esi(lent Roosevelt of a Limited National 
Emergency, and reserve medical department 
personnel who volunteered for service were 
therefore ordered to active duty. The expan- 
sion of personnel that took place is portrayed 
in table 1. 

Table 1. — Increase in Medical Department personnel 
on active duty, 19S9''1945. 

Medical Corps olTicers 

Dental Corps offirors 

Nurse Corps officors 

30 June 1939 

30 Juno 1941 








The naval hospitals and hospital ships in 
commission in 1941 are listed in table 2. For 

the continental hospitals, the comparative cen- 
sus of patients is given for 1941 and 1945, 

^Bureau Divisions: 

Physical Qualifications and Medical Records, Personnel, Den- 
tistry, Aviation, Medicine, Planning, Research, Inspections, Publi- 
cations, Materiel and Finance, and Administration. 

indicating the great increase in demand for 
hospital beds after 7 December 1941. 

Table 2. — Hospitals and hospital ships in commission 

in 19 U 

Paiient ocnsu8 

S. Xav;il H.i.spital. Annapolis, Md. (fi«r. 1) 

S. Xa\al H(>.s{)ital. Hrt-incrton, Wash. (fif;. 2)_. 
S. Naval Hospital, l^ruoklvn. N. Y. (fin. 3)... 
S. Naval Hospital, Cliarlcsi on. S. C. ifis. 4;-_. 

S. Naval l[<»spital, Cliclsca. Mass. ( fm. 5) 

S. Naval Hospital, Corona, Calif, (fig. 0) 

S. Naval Hospital. Corpus Christi, Tex. (tig. 7). 
S. Naval Hospital. Crc:.! f-akcs, 111. (fin. s, 
S. Naval H..spital, .larksonvillc, Fla. <fin. 9) , . 
Naval Hospital. Man- Island. C: 

S. Naval Ho.^pit: 
.S. Naval; 
»S. Naval Hospit; 
8. Naval Hosi)ii; 

if. I fig. 10). 

il. Newport, K. 1. (fig. Ill 

il. i'arris Island. S. C. (fig. 12). 
il. P.'nsarola, Fla. (Iig. 13).__. 
il, Philadelphia, Pa. (fig. 14).. 
t>. Naval Ho.^i^ital. Portsmouth, \ a. (fig. 1.')) .. 
S. Naval Hospital. Portsmouth. N. II. (Ifig. 16). 

S. Naval Hospital, Quant ico. \"a. i fig. 17) 

Naval Hospital. San Diego. Calif, (fig. IS)... 

S. Naval Hospital, Washington. D. C. (fig. lU) _ 
8. Naval Hospital, Pearl Harl)or, T. H._ 

Naval Hospital, Cauaeao, P. I 

. S. Naval Hospital, CJuaiii, M. 1 

8. Naval iMobile Hospital No. 1, Quantanamo 

Bay. Cuba 

. 8. 8. Rditj (fig. 20) 

. S. S. Solace (fig. 21) 




1 .305 

1 ,073 


1 8,069 

^Maximum patient census, 12,068, January 1945. 
2 Decommissioned 1942. 

After the flames of war spread over Pearl 

Harbor, the construction of new hospitals was 
expedited and the bed capacity of existing hos- 
pitals was expanded by adding H4ype frame 
ward buildings and by decreasing the normal 
peacetime 8-foot interval between beds to 6 
jfeet. That the need for additional hospital 
facilities was great is indicated by the follow- 
ing as shown in figure 22: In June 1939 the 
total patient census in naval hospitals was 
4,124; in June 1941 it was 7,723; the average 
census of patients for the year 1942 was 
13,274 ; in 1943 it was 39,723 ; in 1944 it was 
70,576; and in 1945 it was 90,635. 




Figure 1.— U. S. Naval Hospital, Annapolis, Md. 

Figure 2.— U. S. Naval Hospital, Bremerton, Wash. 


— Courtesy af Fair child Air Photos Co. 

Figure 3.— U. S. Naval Hospital, Brooklyn, N.Y, 

Figure 4. — U. S. Naval Hospital, Charleston, S.C. 




Figure 7. — U. S. Naval Hospital, Corpus Christi, Tex. 

Figure 8. — U. S. Naval Hospital, Great Lakes, 111. 



Figure 13. — U. S. Naval Hospital, Pensacola, Fla. 



Figure 14.— U. S. Naval Hospital, Philadelphia, Pa. 

Figure 15. — U. S. Naval Hospital, Portsmouth, Va. 





Figure 19. — U. S. Naval Hospital, Washington, D.C. 


Figure 21. — U.S.S. Solace 



In 1942 alone, nine continental and two 
extiacontinental hospitals were commissioned 

(table 3) : 

Table 3. — Hospitals commissioned in 19J^2 

Patient centnis 

V-J Dnij 

U.S. Naval Hospital, Bethesda, Md. » (fig. 23) ___ 2,426 

U.S. Naval Hospital, San Francisco (Treasure Island), Calif, (fig. 24) 1 ,276 

U.S. Naval Hospital, Oakland, Calif, (fig. 25) 5,400 

U.S. Naval Hospital, Seattle, Wash. (fig. 26)- .3,031 

U.S. Naval Hcspital, Key West, Fla. (fig. 27) 2,609 

U.S. Naval Hospital, Charlo.ston, 8.C 607 

U.S. Naval Ilospilal, Long Reach, Calif, (fig. 28) 2,281 

U.S. Naval Hospital, Norfolk, Va. (fig. 29) _ 1,652 

U..S. Naval Hospitnl, Xorman, Okla. (fig. 30) _ 1,8H 

U.S. Naval Hospital, Balboa, C.Z 192 

U.S. Naval Hospital, Coco Solo, C.Z __ 236 

^ Thi.s was a subordinate command of the National Naval Medical 
Center commissioned 5 February 19i2» and I'eplaaed the U. S, Naval 
Hospital, Washington, 1). C, originally commissioned October 1906. 

Also included in the National Naval Medical Center were the 
following activities : 

U. S. Naval Medical School (orijrinally established 1822). 

U. S. Naval Dental School (oriirinally o.'^tnhli.'^hed 11>2H). 

U. S. Naval Medical Kcseai ch Insliuiie t . stabli.'^hed r.»-12). 

U. S. Naval School of Hospital Administration (reorganized and 
established l'J4.'> ) . 

U. Hospital Co 1 IKS School (Women's Reserve) (commissioned 
UM-} ; decommissioned 1!:»46). 

The cornerstone for the Center wa.'i laid by President Roosevelt 
on 11 November H)4ii. Kear Admiral Charles M. Oman (MC) USN 
was the first commanding officer of the Center. 



Figure 25.— U. S. Naval Hospital, Oakland, Calif. 

Figure 28. — U. S. Naval Hospital, Long Beach, Calif. 



Figure 29.— U. S. Naval Hospital, Norfolk, Va. 

Development of Mobile and Base Hospitals' 

In 1939, when world war appeared immi- 
nent, the Bureau of Medicine and Surgery 
realized the need for some type of prefabri- 
cated hospital that would be completely self- 
sustaining and yet transportable and of such 
construction that it could be set up without 
the employment of skilled mechanics. As a 
result U.S. Naval Mobile Hospital No. 1, which 
is more fully described in chapter III, was 
desi^rned and constructed. This was a 500-bed, 
completely equipped, transportable type, gen- 
eral hospital with self-contained power, water, 
commissary, laundry, and repair facilities. It 
was first set up at Guantanamo Bay, Cuba, 
in November 1940, where it served local and 
fleet units (fig. 31). After its experimental 
phase in Cuba, its portability was tested by 
being torn down, shipped to Bermuda, and 
set up there (fig. 32). The experience in erect- 
ing this type of hospital paved the way for 
better mobile and base hospital construction. 

2 In August 194a the (lesi-tiat ion Mobile Hosi.ital was ehan-ed 
to Fleet Hospital ;new serial numbers wot e assigned by adding 100 
to the old number, except for Mobile Hospitals 1 and 2. which be- 
came Fleet Hospitals 1 and 2 respectively. 

Although it was observed that these hospitals 
did not possess a high degree of mobility, 
nevertheless they could be moved and sset up 
in any area with a minimum of time, expense, 
and labor. They contained the following 
facilities : (a) water purification and softening 
plant; (/)) storage spaces for supplies; (c) 
laundry; (d) galley; (e) automotive and am- 
bulance equipment ; (/) fire-fighting equipment ; 
(r/) light and power supplies; (h) refrigera- 
tion facilities; and (i) x-ray, dental, labora- 
tory, and other equipment and facilities of a 
general hospital. 

Figure 30. — U. S. Naval Hospital, Norman, Okla. 




The supplies, equipment, and buildings for 
all mobile and base hospitals were procured 
by the Medical Supply Depot, Brooklyn, N.Y., 
and each hospital was commissioned there. 
During the period of assembling and packing 
the hospital supplies and equipment, the hos- 
pital staff assembled at the Depot, where they 
were indoctrinated in the methods of hospital 
construction and outfitting and were advised 
regarding the methods of identification of the 
packed and crated equipment. 

Upon reaching their destination the staff of 
the hospital immediately set up temporary 
quarters, and when the material for the hos- 
pital arrived the hospital corpsmen under the 
direction and with the physical assistance of 
the Medical Corps, Dental Corps, and Hos- 
pital Corps officers began the job of unloading 

and sorting the equipment and supplies and 
erecting the prefabricated components of the 
hospital — the quonset, Iceland, and similar 
huts. This was no small task; some of the 
hospitals had as many as 300 buildings, includ- 
ing huts'^ and sheds. 

At first some of the hospitals experienced 
difficulty in obtaining sufficient medical sup. 
plies ; in particular there was a great shortage 
of quinine and atabrine. Many administrative 
difficulties presented themselves. There was 
some confusion regarding the procedures for 
requisitioning supplies, often the allotment 
status was unknown and instructions regard- 
ing accounting procedures were not received, 

3 The floor space of the quonset hut was 16 by 36 feet and of 
the Iceland hut 24 by 36 feet. 

Figure 31. — Mobile Hospital No. 1 at Guantanamo Bay, Cuba. 


Figure 32.— Mobile Hospital No. 1 at Bermuda. 

and some hospitals were uncertain how to 
obtain items not listed in the supply catalogue. 

The size of the mobile and base hospitals 
varied from 200 to 2,500 beds. In the majority 
of the hospitals, the number of medical officers 
attached ranged from 40 to 54, of dental officers 
from 1 to 4, of Hospital Corps officers from 
1 to 5, and of hospital corpsmen from 235 to 
500. Usually about 80 enhsted men with non- 
medical ratings were attached to the hospital. 
There were no civilian employees, and until 
the early part of 1944 none of the hospitals 
had Navy nurses. 

Plans for the construction of mobile and 
base hospitals having been perfected following 
the experiences with the U.S. Naval Mobile 
Hospital No. 1 in Guantanamo and Bermuda, 
similar but improved versions (fig. 33) were 
erected in the battle zones all over the world. 
The first of these, U.S. Naval Mobile Hospital 
No. 2, was disembarked at Pearl Harbor on 
26 Novembei' 1941, just 12 days before the 
attack by the Japanese. By the end of 1942 
8 mobile and base hospitals of 500 beds each 
had been assembled, shipped, and erected in 
battle zones. 



D^9 Samar Palou Islands 


0 Soipan 
*. • Tinlan 
0 Guam 

,# Pearl Harbor 


Eniwetolc • 


<^NEW GUINEA . Admiralty Islands 



FinschhafJ^ ^New Georgia 
^ " - o"^,^ Island 

Munda , ^ 
Milne Bay ^ 

. . NEW HEBRIDES JyEspiritu Santo^ 

Townsville ^ew Caledonia ^ 
\ Noumea 

, Brisbane 

L Tutuila 




9. '-O 


Pearl Harbor 
• Tokelau Naval Hospital, Navy Yard 

Naval Hospital, Aiea Heights 
Mobile Hospital No. 2 

Tutuila ' 
Mobile Hospital No. 3 


Auckland | 
Mobile Hospital No. 4 | 

Mobile Hospital No. 6 



Mobile Hospital No. 5 



Base Hospital No. 2 










F'TOTTRK TT.R. Maval Hospitals in tho PariHr- ir> in/*- 



Figure 34.— Mobile Hospital No. 8 at Guadalcanal. 

Two base hospitals and five mobile hospitals 
were commissioned in 1942 (table 4). 

Tabl£! 4. — Mobile and base hospitals commissioned 
in 1H2 

Base kospUaU: 

V.S. Naval Base Hospital No. 1, Londonderry, North Ireland 
U.S. Naval Base Hospital No. 2, Efate Island, New Hebrides » 

Mobile hospiUUs: 

U.S. Naval Mobile Hospital No, 2, Pearl Harbor (coinmissioned Aug 

U..S. Naval Mobile Hospital No. 3, Tutuila, Samoa; Guam - 
U.S. Naval Mobile Hospital No. 5, Noumea, New Caledonia ^ 
U.S. Naval Mobile Hospital No. 7, Noumea, New Caledonia 
U.S. Naval Mobile Hospital No. 8, Guadalcanal, Solomon Islands 
(fig. 34) « 

Base Hospital No. 2, Efate, New Hebrides, arrived at Villa, 4 
May 1942. It was the first base ho.spital established in the South- 
west Pacific. During the period 4 May 19 42 to 31 December 194 2 
this hospital admitted 2,949 patient.-^ with malaria. Casualties from 
buadalcanal were admitted to Base Hospital No. 2, usually within 
^6 liours after they were injured. Most of the patients were brought 

The U.S. Naval Fleet Hospital No. 103, 
Guam, and the U.S. Naval Convalescent Hos- 
pital, Harriman, N.Y. (fig. 35), were also 
commissioned in 1942. 

by air to an airfield ('> miles from h()S)>ital. A quonset hut for 

the reception of patients was placed near tiie landing? strip of the 
airfield and a medical officer supervised the transfer of patients 
from airplane to ambulance. In 1944 this hospital was moved to 
Noumea and in July 1945 to Subic Bay. 

^Mobile Hospital No. 3, in American Samoa, was one of the 
hospitals established in the Pacific in 1942 that did TU)t receive 
a larj^re number of battle casualties. In Samoa, filariasis was a 
major iiir)l)Iem. Up to I January 1944, this hospital evacuated 
2,9n j jiaiietit.s with filariasis to the United States. 

3 Mobile Hospital No. 5, latej- Fleet Hospital No. 10.5, arrived in 
Noumea in September 194 2 and received its first patients on 22 
April 1943. During- the period from September 1942 to December 
1945, 23,S66 patients were admitted. The maximum patient census 
was 2,100. 

^ Mobile Hosi)ital No. S. arrived on (lUadalcanal in April 1943. 
It was commissioned Aut?ust 194 3 and desi^rnaled as Fleet Hospital 
No. 108 in 1944. By December 1944 this hospital had treated 
39,395 patients. During 1943, 2,208 patients were admitted for 
some form of psychoneurosis. 




Figure 35. — U. S. Naval Convalescent Hospital, Harriman, N.Y. 

In February 1943 the bed capacity of pre- 
viously constructed mobile hospitals was ex- 
panded to 1,000 beds, and in June all base 
hospitals were equipped for 1,000-bed capacity. 
In addition numerous new hospitals were com- 
missioned in 1943 (table 5) : 

Table 5. — Hospitals commissioned in 19Jf3 

Patient cejisus 
V-J Day 

Continental hospitals: 

U.S. Naval Hospital, Farragut, Idaho (fig. 36) 2,489 

U.S. Naval Hospital, Bainbridge, Md. (fig. 37) 1,979 

U.S. Naval Hospital, St. Albans, N.Y. (fig. 38) 4,642 

U.S. Naval Hospital, Sampson, N.Y. (fig. 39) _ 2,119 

U.S. Naval Hospital, Memphis, Tenn. (fig. 40) 1,321 

U.S. Naval Hospital, New Orleans, La. (fig. 41) 1,212 

U.S. Naval Hospital, Camp Lejeune, New River, X.C. (fig. 42) 1,730 

U.S. Naval Hospital, Oceanside, Calif, (fig. 43) 1,5.34 

U.S. Naval Hospital, Shoemaker, Calif, (fig. 44) 3,031 

Exlracontinental h ospitals : 

U.S. Naval Hospital, Aiea Heights, T.H 

U.S. Naval Hospital, San Juan, P. 11 

U.S. Naval Hospital, Trinidad, B.W.I 

Base hospitals: 

U.S. Naval Base Hospital No. 3, Espiritu Santo, New Hebrides. 

U.S. Naval Base Hospital No. 4, Wellington, New Zealand; 

Okinawa (fig. 45) 

U.S. Naval Base Hospital No. 5, Casablanca, French Morocco. 
U.S. Naval Base Hospital No. 6, Fspiritu Santo, New Hebrides 

U.S. Naval Base Hospital No. 7, Tulagi, Solomon Lslands 

U.S. Naval Base Hospital No. 8, Pearl Harbor, T.H 

U.S. Naval Base Hospital No. 9, Oran, Algeria 

U.S. Naval Hospital No. 10, Sydney, Australia 

U.S. Naval I^asc Hospital No. 11, Munda, New Georgia 

U.S. Naval Base Hospital No. 13, Milne Bay, New Guinea 

Mobile hospitah: 

U.S. Naval Mobile Hospital No. 4, Auckland, New Zealand, _ 
L'.S. Naval Mobile Hospital No. 6, Wellington, New Zealand.. 

U.S. Naval Mobile Hospital No. 9, Brisbane, Austraha 

U.S. Naval Mobile Hospital No. 10, Russell Islands, Solomon 


U.S. Naval Mobile Hospital No. 11, Guam, Mariana Islands.. 
I'.S. Naval Mobile Hospital No. 12, New Caledonia (Noumea) i 

Con valescent hospitals : 

U.S. Naval Special Hospital, Santa Cruz, Calif 

U.S. Naval Special Hospital, Ashevillo, N.C... 

L'.S. Naval Special Hospital, Yosemite, Calif, (tig. 46) 

U.S. Naval Special Hospital, Sun Valley, Idaho 

U.S. Naval Special Hospital, Glenwood Springs, Colo. (fig. 47) 


1 Mobile Hospital No. 12 was commissioned in September 194S 
and decommissioned in November 194 5. By receipt and transfer* 
about 1,400 officers and men served with this unit, but it never 
operated as a hospital and never admitted a patient. This hospital* 
arrived at Noumea in May 1944; from there it was shipped to? 
Guadalcanal, Espiritu Santo, Eniwetok, and finally Okinawa. 
was never erected. 



Figure 45. — U. S. Naval Base Hospital No. 4, Wellington, New Zealand 





:* Tinion 
^9 Guam 

. ,^ Pearl Harbor 

Efiiwetok . 

PqIou Islands 

• 0 


NEW GUINEA . Admirolty Islands 


Finschhafe^^^ < 

Milne B-ay ST^^ * 

Guadalcanal ' • ^ r- 
. NEW HEBRIDES ^ Esp.uu Santo 

Townsvllle Kew Caledonia ^ 

. Tutuila 




P«orl Harboc 

Novel Ho«pital, Meenaloo 
Novol Ho*|»ltal, AfM Heights 
Bose Hotpitol No. B 


MebiU Hospital No. 3 



Fle«t Hotpitol No. 105 
FUot Hospital No. 107 


Bas« Hospital No. 4 


Floot Hospital No. 104 
Mobil* Hospital No. 6 


Beso Hospital No. 7 

Espiritu Sonto 

Bose Hospitol Ho. 3 
Boso Hospital No. 6 



Fleet Hospital No. 108 

Bete Hospiial No. 7 
Russoll islands 

Fleet Hospital No. 110 
Mundo, New Georgia 

Bos* Hospital No. 1 1 



Fleet Hotpital No. 109 

Bote Hospitol No. 10 


Milne Boy 

Base Ho«pitol No. 13 

Base Hespitel No. 14 

Bos* Hospital No. 17 



Base Hospital No. 18 

Bos* Hospital No. 19 


Bos* Hospitol No. 15 

Bate Hospitol No. 16 


Palou Islands 

Base Hospital Ho. 20 


San Francisco 

Fl*et Hospital No. 113 











Figure 48. — Mobile and base hospitals in the Pacific in 1944. 



Figure 48 shows the location of mobile and 
base hospitals in the Pacific during 1944. In 
that year the hospital facilities listed in table 6 
were commissioned. 

Table 6. — Hospitals and hospital ships commissioned 
in 19 H 

Patient census 
V-J Day 

Continental hospitals: 

U.S. Naval Hospital, San Leandro, Calif, (fig. 49) J.gv^ 

U.S. Naval Hospital, Fort Eustice, Va. (fig. 50).-- l.^^y 

U.S. Naval Hospital, Astoria, Greg '^l^ 

Base hospitals: . ^ ^ i 

U.S. Naval Base Hospital No. 12, Netley, Hants, England 

U.S. Naval Base Hospital No. 14, Finschhafcn, New Guinea; 

Cavite, P.I. f V",-- *-r""~i:" 

U.S. Naval Base Hospital No. 15, Manus Island, Admiralty 

Islands , vr~"T — 

U S Naval Base Hospital No. 16, Woendi, Schouten Islands. _ 

U.S. Naval Base Hospital No. 17, Hollandia, New Guinea 

U S. Naval Base Hospital No. 18, Guam, Mariana Islands. _-- 

U.S. Naval Base Hospital No. 19, Tinian Island, Mariana 

Islands zct-.-:--w-^ — 71""^ 

U.S. Naval Base Hospital No. 20, Peleliu, Palau Islands.- -- 

Fleet hospitals: „ „ . ^ 

U S. Naval Fleet Hospital No. 113, San Francisco, Calif. --- 

U.S. Naval Fleet Hospital No. 114, Samar, P.I. ^ 

Hospital ships: 

IJ.S.S. Bountiful.. .-- 

U.S.S. Refuge --- 

U.S.S. Samaritan (fig. 51) 

Convalescent hospitals: ijo- vr rq9 

U S. Naval Special Hospital, Arrowhead Springs, Calif oy^ 

U.S. Naval Special Hospital, Banning, Calif. o^l 

U.S. Naval Special Hospital, Beaumont, Calif ^4U 

U.S. Naval Special Hospital, Sea Gate, N.Y boj 

U.S. Naval Special Hospital, Springfield, Mass 

1 Fleet Hospital No. 114, a 1.000-bed unit, arrived at Samar, 
March 1945. and was expanded to 3.000 beds by incorporating 
Fleet Hospital No. 109. The hospital was operating on 2 July 1945 
and 5 684 patients were admitted during the 2 months of July and 
August. This hospital had a strikingly high incidence of admissions 
for ureteral calculus, 117 admissions in 2 months. The widespread 
use of sulfonamides may have been a factor in this. 

In 1945 the hospital facilities shown in tab 
7 were commissioned: 

Table 7. — Hospitals and hospital ships commissione 
in 19Jf5 

Patient cei 
V-J D 

Continental hospitals: 

U.S. Naval Hospital, Dublin, Ga. (fig. 52) 

U.S. Naval Hospital, Corvallis, Greg. (fig. 53) 1.57 

Base hospitals: 

U.S. Naval Base Hospital No. 21, Kwajalein Island, Marshall 

Fleet hospitals: 

U.S. Naval Fleet Hospital No. 115, Guam, Mariana Islands.. 
U.S. Naval Fleet Hospital No. 116, Brooklyn, N.Y.; San Pedro, 


Hospital ships: 

U.S.S. Benevolence 

U.S.S. Consolation (fig. 54) 

U.S.S. Haven (fig. 55). --- 

U.S.S. Repose 

U.S.S. Rescue (fig. 56) 

U.S.S. Sanctuary 

U.S.S. Tranquillity (fig. 57) - 

Military government hospitals: 

U.S. Naval Military Government Hospital, Saipan, Mariana 

U.S. Naval Military' Government Hospital, Guam, Mariana 
Islands - - — ^.------.-7 w" " " — 

U.S. Naval Military Government Hospital, Tinian, Mariana 


Special augmented hospitals: 

Special Augmented Hospital No. 3, Okinawa, Ryukyu Islands.- 

Special Augmented Hospital No. 4, Okinawa, Ryukyu Is ands.. 

Special Augmented Hospital No. 6, Okinawa, Ryukyu Islands. - 

Special Augmented Hospital No. 7, Okinawa, Ryukyu Islands.. 

Special Augmented Hospital No. 8, Okinawa, Ryukyu Islands. . 

Convalescent hospitah: 

U.S. Naval Special Hospital, Asbury Park, N.J 

U.S. Naval Special Hospital, Palm Beach, Fla 1,« 

U.S. Naval Special Ilcspital, Camp White, Oreg 

U.S. Naval Special Hospital, Camp Wallace, Tex 

Figure 49. — U. S. Naval Hospital, San Leandro, Calif. 



2380ir>-53 1 

Figure 51. — U.S.S. Samaritan 


Figure 55.— U.S.S. Haven. 



Figure 56. — U.S.S. Rescue. 

Figure 57.— U.S.S. Tranquillitij. The first of six 15,000-ton hospital ships of the Haven class to be converted from 
Maritime Commission C-4 hull. These vessels were completely air conditioned and the medical facilities were eqi 
to those of a large modern hospital. 




At the end of the war there were in com- 
mission 42 naval hospitals and 12 naval con- 
valescent hospitals in the continental United 
States. Overseas there were 6 permanent hos- 
pitals, 36 mobile, base, or fleet hospitals (figs. 
58 59, 60), 12 hospital ships, 3 hospital trans- 
ports, and 3 military government hospitals. 
Logistic support was furnished by 32 medical 
supply facilities, depots, warehouses, and sup- 
ply barges (table 8) . 

Table 8. — Medical supply facilities , all types 

Medical supply depots: 
Brooklyn, N.Y. 
Oakland, Calif. 
Pearl Harbor, I.TT 

Guam, Mariana Islands (Annex at fc»aipan; 

Medical supply storehouses and slora^je facilities in the United States: 

Nowport, R.I. 
Charleston, S.C. 
Seattle, Wash. 
San Pedro, Calif. 

San DicKC Calif. 

Naval Supply Depot, Mechaniesburg, Pa. 
Naval Supply Depot, Spokane, Wash. 
Naval Supply Depot, Clearfield, Utah. 

Mfth'rftl siippli/ itfon-housi's oversea.'^: 
Bulljoa, C.Z. 

Londonderry, North Irohind 

Exeter, EnKlnnd 

Sydney, Australia 

Auckland. New Zealand 

No. 1, Subie Hav, Philippine Islands 

No. 3. Kodiak. Alaska 

No. 4, Satnar. Philippine Islands 

No. 7, San Juan, P.P. 

No. y, Casaldanea, French Morocco 

No. 10, Recife, Brazil 

No. 11, Espiritu Santo, New Heortdea 

No. 13, Saipan, Mariana Islan Is 

Supply Faeiiity Fleet Hospital 105, New Caledonia 

Supply barges: 
U.S.S. Silica 
U.S.S. Lignite 
r.S.S. Mare 
VF 7S7 
YF 73S 
^'F 730 
VF 740 
VF 754 


Mobile and base hospitals successfully treated 

thousands of patients dui-ing the war, but they 
never attained the degree of mobility desired 
for combat areas. The deficiencies of the mobile 

(fleet) and base hospitals in combat areas were 
noted in the Seventh Fleet report for 1944 : 

Althouo^h fleet and base hospitals as presently planned 
are excellent as to comfort for patients and working 
conditions for Medical Department personnel, they 
possess distinct disadvantages. They are bulky and 
require considerable shippinja: space to transport, time 
and effort to establish, and even more effort to dis- 
mantle, refit, and move forwai'd. In a fast moving type 
of warfare over the vast distances typified in the 
operations in the Southwest Pacific, hospitals have not 
been capable of receiving casualties until the assault 
beaches moved far ahead. With the consistent shortage 
of AH's, APH*s, and APA's in the Seventh Fleet, it 
was necessary in many areas to resort to hospitalizing 

Figure 58.— Main ward buildings, Base Hospital No. 4, Wellington, New Zealand. 



■naval patients in Army hospitals. The latter were easily 
transported and quickly erected, and while they did 
-not afford many of the i-efinements of the less mobile 
naval hospitals, they otfered excellent early care to 

casualties at a time when the need was urgent. Canvas- 
housed, truly mobile hospitals are a paramount need 
in amphibious warfare, both for Army and Navy 


Special Augmented Hospitals 

In 1945, in the closing months of the war, 
a new type hospital, the Special Augmented 
Hospital, was used for the first time on Okina- 
wa. In compQsition and function it was inter- 
mediate between a Marine Corps field hospital 
and the fleet base hospitals that had been used 
throughout the w^ar in the Pacific. These special 
augmented hospitals were designed to bring 
hospital services and specialized care to per- 
sonnel in the combat area. 

Plans were made by the Bureau of Medicine 
and Surgery for 8 of these new hospitals. 
Four were to have a bed capacity of 200 each 
and 4 to have a bed capacity of 400 each. Of 
the number planned, 5 left the United States 
for Okinawa. 

Personnel for the special augmented hos- 
pitals were assembled at San Bruno, Calif., 
in the late summer of 1944. There they were 
given comprehensive physical conditioning 
which included hiking and camping expedi- 
tions under conditions that approximated those 
in the field of combat. The men lived in tents, 
ate from mess kits, practiced field sanitation, 
and were instructed in infiltration tactics, the 
use of the rifle, tent construction and main- 
tenance, and chemical warfare. Special groups 
received instruction in tropical diseases at 
Treasure Island, Calif. General duty corpsmen 
were given refresher courses and some men 
were detailed to Navy hospitals for training 
in the specialties, such as laboratory and 

Special Augmented Hospital No. 6 was com- 
missioned on 7 March 1945, and 3 days later 
Special Augmented Hospital Nos. 3, 4, 7, and 8 
were commissioned. Special Augmented Hos- 
pital No, 6, the first to sail, arrived at Okinawa 
on 4 May 1945, and received its first patients 
on 17 June 1945. Special Augmented Hospitals 
Nos. 4, 7, and 8 arrived on 14 July 1945. Of the 
five special augmented hospitals to arrive in 
Okinawa, only Nos. 3 and 6 actually received 
patients before the surrender of Japan. The 
others received their first patients in Septem- 
ber, and continued to care for them for several 
months after the war. 

Regarding the function of the ''Augmented'' 
Hospital, the following comments were made : 

Although the exact place of the augmented hospital 
was never made clear, nevertheless, certain comments 
can be made. If it was Intended that this type of 
hospital should be in operation during the active 
campaign for the island, then its equipment and 
construction contained too much of a semipermanent or 
permanent character, so that it could not be erected 
quickly. On the other hand, if it was intended that this 
hospital should come into operation after the termina- 
tion of hostilities, as was the case, then its construction 
was too temporary in character to afford desired com- 
fort and efficiency. 

Not knowing w^hat were the planned cxpt'clations 
for such a hospital, it was difficult to jud^^e its effective- 
ness. Probably the most effective function of this 
hospital was the ability to keep beds available for the 
demand for admissions which was placed upon it; how- 
ever, because evacuation had to be made so frequently, 
prolonged treatment, elective surgery, and complete 
diagnostic procedures had to be curtailed. 

Medical FaciliHes; European, Atlantic, & African Theaters 

Two base hospitals were established in the 
United Kingdom. The 300-bed Naval Base 
Hospital No. 1 at Londonderry. Ireland, was 
commissioned in February 1942 and provided 
hospitalization and outpatient service for per- 

sonnel of the Allied Services as well as of the 
U.S. Navy. Naval Base Hospital No, 12 was 
set up in the Royal Victoria Military Hospital 
at Netley, Hants, Southampton, w^hich was 
turned over to the Navy on 28 February 1944. 



A fuller account of its development as a 1,000- 
bed hospital and of its outstanding achieve- 
ments is given in chapter III. 

Naval Ease Hospital No. 12 was established 
primarily for the treatment of casualties dur- 
ing the Invasion of Europe. The first D-day- 
casualties were received on 9 June 1944 and 
in the following 4 months a total of 7,877 
patients (including 4,226 war casualties) were 
admitted. There were only 18 deaths during 
this period, 11 of these the result of wounds 
incurred in action against the enemy. The 
mortality rate of combat casualties was only 
0.26 percent. 

Prior to the establishment of this hospital, 
all U.S. Navy patients requiring return from 
the European area to the United States for 
further treatment or disposition were evacu- 
ated through the U.S. Naval Dispensary at 
Roseneath, Scotland. Evacuations through the 
Base Hospital proved more satisfactory because 
of its proximity to the southern ports where 
there were fewer travel difficulties. After it 
was decommissioned on 30 September 1944, 
U.S. Naval Advanced Amphibious Base, Ply- 
mouth, Devon, and U.S. Naval Base No. 2. 
Roseneath, Scotland, were designated as evacu- 
ation centers for the southern and northern 
areas respectively. 

At Camp Knox, Reykjavik area, the head- 
quarters of the Naval Operating Base, Iceland, 
a dispensary was alread\^ functioning in July 
1942. It had 21 huts and contained 109 beds. 
During 1942, approximately 75 percent of the 
patients were from ships operating in Iceland 
waters. This dispensary was centrally located, 
well staffed, and equipped to meet hospital needs 
of Navy personnel stationed in Iceland or in 
ships operating in Icelandic waters. Auxiliary 
dispensaries were established at the Tank Farm 
and at Falcon Comperea at Hoalford, as well 
as at the Fleet Air Base, Reykjavik. 

Dispensary facilities in the United Kingdom 
were located at the activities listed in table 9, 
and other dispensaries were established at 
Saltash, Appledore, Falmouth, Fowey, Sal- 
combe, Dartmouth, Teignmouth, Penarth and 
Milford Haven, St. Mawes, Poole, Portland- 
Weymouth, Southampton, Deptford, Exeter, 
and Calstock. On 15 June 1944 a dispensary 

of 50 beds was set up in Elackheath, London^ 
to care for convalescent and overflow patients, 
from the main dispensary and to serve as a! 
dressing station for bomb casualties. During 
the 5-month period prior to D-day, the number 
of available beds in England for reception of 
casualties had reached 3,500. 

Table 9. — Dispensaries in the United Kingdom 



rSX Base, Roseneath. Srotlan.l . 

LTSNAATB, Applr.lnr.-. Dcvuii 

ITSNAATSB, St. Mawes. ( urnwall 

USNAAB, Falmouth. Cornwall 

USNAATSB. Fowev . CornwalL „_ 

L'SNAAB, Plymouth, Devon 

USNAATSB, Salcombe, Devon 

USNAATSB, Toignmoulh, Devon 

USNAAB, Dartmoutli, Devon 

USNAAB, Milford Havon, Wales 

USNAAMSB, Penarth, Wales. 

USNASB, Exeter, Devon 

USNAAMB, Deptford, London 

USNAAB, Portland-Weymouth. Dorset. 

USNAAB, Poole, Dorset 

USNAAB, Southampton, Netley, Hants. 

The hospital and dispensary facilities estab- 
lished in the European, Atlantic, and North 
African theaters are shown in figures 61, 62, 
and 63. 

Table 10. — Hospitals and dispensaries in the Atlantic 

Bed capacity 

Canal Zone: 

N.aval lio.spit:il <^.W 

Di.'^pensary (ntiviil station) 8 

Marine sick l)ay (annex to naval .station) 14 

Si<'k l)av, navai aininunitiou depot 4 

dn;, Solo: 

' Xaval hospital 464 

Dispensary (naval station) 30 

Disr>ensary (Crisrol)al Annex to naval station) 4 

Dispensary, naval air station 90 

Far/an: Sick bay ira.<lio station) 

Tobaao Tslftnd: Dispensary (naval station). 20 

Galajxigos Idund: Dispensary (naval base) --- 15 

Puerto Costilla, Honduras: Dispensary (naval base) _ 14 

Corinto, Nicaragua: Dispensary (naval base) -- 16 

Barranquilla: Dispensary (naval base) - j 

Netherlands West Indies: Curacao (naval camp). 2o 

Vir>/ii' L^londs: St. Thonias naval station 10 


Caravellas. .lispensary 

Maceio. dispensary ^ 11 

Rio de Janeiro. Dispensary (naval operating facility) 8 

Santa Cru/, Dispensary 1^ 

British Wt.^t Indite: 

Antigua (N.A.A.F.) - - — — f 

Great Exuma (N.A.A.F.) 4 


Hospital - 

NAS dispen.sary ^ 


Guantananio Bay: 

Naval station . — *- — --^ 

Naval air station — 

Marine Corps Base * 

Puerto Rico: , > , ^ ^. v t 

Roosevelt Roads (naval station) ' 

San Juan: . „^ 

Naval hospital- — - 200 

Naval air station — - 

Figure 61. — ^Naval hospitals and dispensaries in the European Theater. 






?0 - 

^^^ ^^ Reykjavik 

^ Caravellas 


Rio de Janeiro LEGEND 



Figure 62. — Naval hospitals and dispensaries in the North and South Atlantic Theaters. 



As the forces moved into North Africa, dis- 
pensaries were established there. Two days 
after the landing operation had started, on 
10 November 1942, naval medical personnel 
set up a small sickbay in a camel barn on 
the dock of Fedala. Later, dispensaries were 
set up at Oran, Port Lyautey, Arzew, Bizerte, 
and Casablanca. Because of the importance 
of Casablanca as a port of entry and as an 
evacuation center, the dispensary there later 
became U.S. Naval Base Hospital No. 5. Dis- 
pensaries were established at Fedala, Safi, and 
Agadir in French Morocco, and sickbays of 
varying sizes were set up at Mers-el-Kebir, 
Algiers, Nemours, Beni Saf, Mostaganem, 
Tenes, Cherchel, and Dellys in Algeria. By 
summer of 1943 it was obvious that a naval 
hospital was required for personnel in the 
Northwest African waters, and to meet this 


need U.S. Naval Base Hospital No. 9 was 
disembarked at Oran on 3 September 1943. 
With the assistance of construction battalions, 
this 500-bed, completely equipped hospital was 
ready to receive patients 2 months after con- 
struction began. 

In Sicily a 50-bed dispensary was established 
at Palermo and smaller units were set up on 
the south coast of the island. In September 
1943, all U.S. Navy activities in Sicily were 
consolidated at the Naval Operating Base, 
Palermo, where a dispensary of 160 beds was 
established. Later in 1944, 25-bed dispensaries 
were established at Calvi, Bastia, Ajaccio, Cor- 
sica, and at La Maddalena Island, Sardinia 
(table 11). The largest and most important 
dispensary in Italy was at Naples, but Salerno 
and Rome each had a small dispensary. 

Dispensaries were set up on the French 

Table 11. — Medical Department facilities in the African Theater, 1 January 1945 



Arzew, Dispensary U. S. Naval Station 

Oran, Base Hospital No. 9 

Oran, Dispensary, U. S. Naval Station 

French Morocco: 

Agadir, Sick Bay, FAW 15, Detachment No. 1 

Casablanca, Base Hospital No. 5 

Port Lyautey, Dispensary (NAS) 

Tunisia: Bizerte Dispensary, AATB 

Corsica: Dispensary, Ajaccio 






Palermo Dispensary, NOB Sick Bay (port area) 

Dispensary, Palermo 


Naples Dispensary, USN Detachment 

Rome, Dispensary (SENALUSLO) 


La Maddalena Is. PT Base No. 12__ __. 

Dispensary, La Maddalena Island 


invasion beaches, Omaha and Utah, on 12 July 
1943. Later, after the ports became available, 
dispensaries were established at Cherbourg, 
Le Havre, Chateau de La Prunay, Louvecinnes, 
and Seine-et-Oise. The most important medical 

installation in southern France was the dis 
pensary at Marseilles, established after thd 
Normandy invasion. On the heels of the Allied 
crossing of the Rhine, 50-bed dispensaries were 
established at Frankfort and Berlin, Germany. 

Submarine Medicine^ 

Prior to World War II there were about 8 
medical officers in the Navy who were qualified 
in submarine medicine and therefore particu- 
larly interested in the sanitary and hygienic 
aspects and the safety problems of life in a 
submarine. They had been trained primarily 
in deep-sea diving and were familiar with 
the construction and operation of a submarine, 
the problems of submarine escape and salvage, 
the use of the rescue ''bell'' and the submarine 
escape ''lung,'' and the operation of the training 

tank. With the advent of war a great many 
more officers trained in submarine medicine 
were immediately required and the facilities of 
both the Deep Sea Diving School, Washington, 
D.C., and the Submarine Base, New London. 
Conn., were activated. For the first 2 years 
of the war these medical officers, like their 
predecessors, were trained primarily in deep- 

* Adapted from the BuMed publication "The History of Subma- 
rine Medicine in World War II" by Capt. C. W. Shilling (MC) USN 
and Mrs. J. W. Kohl. 



sea diving, and so were not prepared to cope 
with all the medical aspects of submarine duty. 
When the inadequacy in training became ap- 
parent, the course was lengthened by 3 weeks, 
and beginning June 1943 the training included 
'*tank instruction and escape, inspection and 
instruction trips on submarines, dark adapta- 
tion instruction, and similar matters/' as well 
as '^demonstration of diving equipment, lec- 
tures, and demonstrations and .... participa- 
tion in the submarine personnel and sound 
listening personnel selection system/* 

A deterrant to efficient submarine medicine 
in the early part of the war was the necessity 
of at times assigning to a submarine base, 
submarine tender, or submarine squadron, a 
senior medical officer who was not trained or 
qualified in submarine medicine. In March 
1944, when qualification'' in submarine medi- 
cine became a prerequisite for such assign- 
ments, a broad program of submarine medicine 
was activated. Distribution of medical supplies 
was then reorganized and a careful check was 
made of the physical condition of submarine 
personnel before going on patrol or immedi- 
ately upon return. Pharmacist's mates attached 
to submarines were indoctrinated in special 
phases of submarine medicine, a pool of grad- 
uates of the '^School of Pharmacist's Mates 
entering the Submarine Service'' was estab- 
lished, and a system of refresher training for 
those in the pool was inaugurated. 

When the V-boats were commissioned in 
1924, medical department personnel were not 
assigned to the submarines. With improvement 
in submarine design, long cruises became rou- 
tine and there arose the need for Hospital 
Corps personnel aboard. The assignment of 
hospital corpsmen was a success, for a good 
pharmacist's mate proved to be one of the 
most valuable members of the crew, not only 
because of his specialized knowledge but also 
because of his influence on the morale of the 
crew. How well they performed is a matter 
of record — the superb manner in which they 
carried out their assignments during World 
War II is attested to by the commendations 
and awards they received. 

To j^rive recognition to submarine medicine, those medical offi- 
cers (lualified in submarine medicine were authorized to wear the 
distinctive insignia in 1943. 

Early in the war, Hospital Corps personnel 
assigned to submarines were obtained from 
the forces afloat or ashore and were given 
a course of indoctrination in submarine opera- 
tion at the Submarine School, New London, 
Conn., prior to assignment to duty in sub- 
marines. As the war progressed it became 
apparent that not all Hospital Corps personnel 
assigned to submarines had been adequately 
trained. In June 1943 a School for Pharmacist's 
Mates entering Submarine Service was estab- 
lished; there the 6 weeks* course included 
didactic and practical instruction in first aid 
and minor surgery, hygiene and sanitation, 
materia medica, toxicology, anesthesia, labora- 
tory procedures, pharmacy, chemistry, and 
indoctrination in the environmental factors of 
life in a submarine. After March 1945 only 
men who were graduates of the Hospital Corps 
School were assigned to the "School for Phar- 
macist's Mates entering the Submarine Serv- 
ice.'' Graduates of this school were invaluable, 
for they not only provided care for the sick 
and injured in a highly etiicient manner but 
also performed general operational duties such 
as sonar operator, radar operator, lookout, and 


Prepatrol examinations of all personnel were 
conducted to make certain that no man who 
was physically or emotionally below par was 
permitted to go on patrol. Such men were 
transferred to a rest camp. Elaborate facilities 
for rest and recreation were established at 
the Royal Hawaiian Hotel as well as on Mid- 
way, Majuro, Guam, Saipan, Maniis, and Milne 
Bay. Immediately after return from patrol 
another complete physical examination, includ- 
ing roentgenograms of the chest, was done by 
qualified submarine medical officers. A com- 
plete dental examination was also made and 
the needed dental repairs recorded. Results of 
both the physical and dental examinations were 
entered upon cards, which were filed aboard 
the ship and formed a continuous history of 
the physical condition of each man. Upon trans- 
fer to another submarine force activity, the 
history card was transferred to the receiving 
unit. If transferred out of the submarine serv- 



ice, the card was filed at SubBase, Pearl Har- 
bor. The pharmacist's mate in each submarine 
was required to make appropriate entries on 
the history card while on patrol. Thus the 
medical problems and health conditions occur- 
ring on patrol were reported to the Force 
medical ofl^cer by recording and forwarding 
to him a summary of the data on the history 

Although the standard Health Record pro- 
vided a continuous history, it failed to serve 

the purpose of these cards in that only serioug 
conditions warranting admittance to the sick 
list w^ere entered in the health record, and at 
each re-enlistment the history sheets were re^ 
moved and sent to the Bureau. The cards thus 
filled a void. 


Facilities for medical care of submarine per- 
sonnel during World War II (figs. 64, 65), 
were similar to those in small craft, but many 


Figure 64. — Minor surgery aboard a submarine. 

Figure 65. — Medical locker in a submarine. 



nroWems of medical supply required solution. 
As an example there was need for a complete 
and exhaustive study of the medical supplies 
and equipment allowance for submarines. Re- 
plenishment of supplies for submarines should 
have been accomplished either from a sub- 
marine tender or a submarine base and not 
from a medical supply depot, because the small- 
est amount such an activity ordinarily issued 
was too large for a submarine where storage 
space was an acute problem. In the newer type 
submarines, such as the guppy-snorkel, the 
storage problem was even more critical. 

The pharmacist's mate in a submarine needed 
a handbook which outlined medical and surgical 
diagnosis and care, and described the pharma- 
cologic action and indication for use of each 
medical item in stock. The handbook which 
was available during the war did not in any 
sense meet the requirements, and it was neces- 
sary to m.imeograph and distribute to sub- 
marine pharmacist's mates all types of instruc- 
tion for medical care as the occasion arose. 


Submarines rescued 549 survivors, in air-sea 
rescue operations. The part played by the phar- 
macist's mates in this undertaking was very 
important, for 48 percent of the rescued avia- 
tors required medical care because of serious 
injury. The following excerpts from patrol 
reports indicate how well the pharmacist's mate 
cared for his patients: 

One man received a severe laceration of the forearm 
which required seven stitches. Two men were injured 
by misfire of the 20-mm. gun; in one it was deemed 

necessary to amputate two toes of the right foot. Due 
to a shortage of surgical instruments, a pair of 
sterilized side cutters were used to cut portions of the 
shattered hone. Because the ''phalanges — were com- 
pletely shattered, they were not sutured but left open 
to allow free drainage. A g^enerous amount of sulfa- 
nilamide powder was used. The other mm was wounded 
in the shoulder but no load or foreign body could be 
located. This man was back to duty in three days. 

The medical department, in the person of the Chief 
Pharmacist's Mate, did a particularly capable job in 
handling the Jap prisoner of war recovered after his 
plane was shot down. Though suffering from shock, 
second degree burns of the face and hands, and several 
other serious wounds from gunshot and the crash, he 
Was brought around very well and will probably recover. 

An injured German prisoner was treated for a dis- 
located left knee, broken right collar bone, badly 
lacerated mouth and nose, and three missing teeth. 
Recovery was satisfactory except that he succeeded in 
misaligning his clavicle after it was lined up properly. 

The price of sinking one sampan, damaging one, 
and learning the use they are put to (as submarine 
traps) was three men wounded. One man received two 
.25 caliber hits in the left side, one bullet ranging 
upward, fracturing the rib and puncturing^ the left 
lung, the other bullet lodging in the diaphragm. A 
second man received five hits in the right shoulder; 
the third was struck in the right hip by a piece of 
flying metal. In view of the nature of the wounds, left 
the area 24 hours early, setting course for Midway at 

best speed. The Chief Pharmacist's Mate 

is particularly commended for his quick and efficient 
action in caring for these three wounded shipmates. By 
his proficient skill and painstaking efforts he prevented 
complications and enabled return of his patients to 
the facilities of a hospital, well on the road to recovery. 
He has been lecommended for promotion and the 
Bronze Star Medal. 

One man suffered a compound fracture of his right 
ring finger and a simple fracture of his index finger 
when a storeroom hatch cover fell on his fingers. The 
boat was dived to a hundred feet to furnish a stable 
platform for sewing up the fingers and setting the 
bones. While the finger tips are still stiff one month 
after the accident, they are healed nicely and 
PhMlc is to he commended for his effi- 

ciency and skill. 

The , on her second patrol, established 

an all time record for the recovery of friendly aviators, 
when in five rescues she picked up a total of 30 men. 
The first man, recovered on 25 May 1945, had severe 
lacerations and second degree burns. Five days later 
5 more men were recovered, all in good condition, 18 
minutes after their plane had crashed. On 29 May, 16 
men were rescued, 2 of whom were seriously injured; 
1 had severe head and body injuries, the second had a 
possible fracture of the back and skull. One man of 
this group died. 


Injuries aboard combat submarines were 

commonly sustained by personnel on the bridge, 
particularly during the lightninglike maneuvers 
necessary to clear the bridge in the relatively 
few seconds that elapsed between the time 
the diving signal was given and the submarine 
submerged. Crushed fingers, broken ribs, dis- 
locations, bruished shoulders, and lacerations 
of various degrees resulted from the sudden 
exodus of men from the bridge through a 



24-inch hatch and down the slippery and pre- 
cipitous ladder into the conning tower. 


Probably no other single disease caused more 
anxiety to submarine personnel than appen- 
dicitis. Because medical officers were not car- 
ried on submarines, it became important to 
formulate and promulgate a policy governing 
the treatment of appendicitis. All pharmacist\s 
mates in the submarine service and those in 
the ''School for Pharmacist's Mates entering 
Submarine Service'* were impressed with the 
fact that in untrained hands the diagnosis of 
appendicitis is difficult and that gastrointes- 
tinal disturbances and constipation which are 
common in personnel in submarines add to 
the difficuly in diagnosis. The order. ''Never 
resort to surgery/^ and "Never give a cathartic 
to a patient suspected of having appendicitis," 
was put into effect toward the end of the first 
year of the war, and a conservative method 
of treatment was outlined. 


The diagnosis of acute appendicitis was 
made 78 times in 1943 (8.9 cases per thousand) 
and 124 times in 1944 (9.2 cases per thousand), 
in personnel attached to submarines. Pharma- 
cist's mates made the diagnosis of appendicitis 
(acute, chronic, or diagnosis undetermined and 
admitted for observation) on 116 war patrols 
in 127 instances during the entire war. On 
8 patrols more than 1 man was admitted with 
this condition. In 16 instances one case of 
appendicitis was reported from the same sul)- 
marine on 2 successive patrols, presumably by 
the same pharmacist's mate. In 34 instances 
the patient was sufl^ciently ill to warrant trans- 
fer for treatment. Twelve men in whom the 
diagnosis of appendicitis was made during 
the patrol are known to have had surgical 
treatment upon arrival in port. 

Throughout the war in the submarine force, 
not one death from appendicitis was reported. 
Commanding officers were so impressed with 
the performance of pharmacist's mates in han- 
dling these emergencies that in 22 instances 
they were especially commended. 


Regardless of the order not to perforu^ 
appendectomy on personnel in submarines this 
operation was found necessary on several oc. 
casions. An appendectomy was done by a phar. 
macist's mate aboard the U.S.S. Seadracjon 
on 11 September 1942. Subsequent to the oper! 
ation, which lasted about 3 hours, the patient 
was ill for 14 days. Higher authority observed 
in connection with this operation: 

The incident ... is believed to be the first of its kind 
in submarine history. While this case had a happy end- 
ing-, it is pointed out that this particular pharmacist's 
mate had had considerable experience in assisting- at 
surgical operations ... it is hoped that his success will 
not encourage others to take . . . risks. 

In another instance, on board the U.S.S. 
Graijback, in December 1942, the patient had 
been ill for about 48 hours before he was 
operated on. At the operation, which lasted 
about 1/2 hours, the appendix was found to 
be ruptured. Sulfanilamide powder was in- 
stilled, drainage was instituted (an elastic 
rubber band), and the abdomen was closed. 
Ether, administered by a submarine escape 
lung mouthpiece, was used as an anesthetic. 
Spoons were flattened for use as retractors, 
and long nose pliers from the engine rooi^^ 
were also employed. The first assistant wal 
a motor machinist's mate, first class. 

In the third instance an operation for appen- 
dicitis was performed aboard the U.S.S. Silver^ 
sides on 22 December 1942, The patient had 
been ill for about 12 hours prior to the opera- 
tion, which was performed on the wardroom 
table, with the submarine submerged at lOO 
feet. The effectiveness of the spinal anesthesia 
having worn off, **Ether was administered, 
following the directions on the can. This anes- 
thetized the operating staff as well as the 
patient. One hour after completion (the opera- 
tion lasted about 4 hours) we tangled with 
a destroyer. The patient was convalescing the 
following morning to the tune of torpedo firing, 
two depth charge attacks, two 'crash dives' 
and an aerial which knocked him out 
of his bunk. The conduct of the patient . . . was 
exemplary throughout the operation and the 
period following." 




Comments made by the commanding officer 
of one submarine concerning the operation 
performed aboard his ship are pertinent. 

It is recommended that all men who have a history 
or indications of chronic appendicitis not be sent out 
on patrol until their appendix has been removed. This 

ilso aiM^^i^'"^ other ailment which may require an 

^^j-j^gi-o-cncy operation at some future date. 


No health problems entirely peculiar to the 
submarine service existed. As in all other 
branches of the military forces, the most com- 
mon ailments were acute infections of the 
upper respiratory tract, injuries, and diseases 
of the gastrointestinal system. 


A high incidence of ''colds'' was commonly 
expsrienced during the first 3 weeks of a cruise, 
even in tropical waters. Protective clothing 
was inadequate for patrols in northern opera- 
tional areas, particularly in the winter when 
the interior of the ship was cold and damp, 
and "colds'' commonly occurred during the 
passage from warm to cool operational areas. 
The most practical prophylaxis was afforded 
by optimal atmospheric and living conditions 
while on patrol and carefully supervised recu- 
peration at rest centers. The effectiveness of 
germicidal lamps aboard submarines warranted 
investigation. A battery of such lamps was 
installed in one submarine, but the ship's loss 
prevented adequate evaluation. 

Acute upper respiratory diseases such as 
catarrhal fever, sore throat, and tonsillitis 
were reported on over 400 patrols. On 211 
patrols they accounted for 1,068 man-days lost. 
Upon occasion the incidence of these diseases 
aboard submarines on war patrols assumed 
such proportions as to interfere with the opera- 
tion of the ship. At times as many as 70 per- 
cent of the crew were affected. 


Prolonged residence in submarines where 

sunlight was absent and outside ventilation 
was limited to parts of each day was considered 
conducive to activation of quiescent tubercu- 

258015—58 3 

losis and to droplet spread of the disease. Roent- 
genograms of the chests of submarine per- 
sonnel were therefore taken periodically. It 
was found, however, that the incidence of 
tuberculosis in submarine crews, ranging from 
0.41 to 0.43 percent, was the same as that 
in the crews of surface craft, but was hipfher 
than the 0.32 percent incidence in the fleet 
as a whole. 


Diseases of the digestive system accounted 
for 24.1 admissions per thousand. The four 
most common conditions noted on war patrols 
were acute gastroenteritis, chronic constipa- 
tion, acute appendicitis, and "diagnosis unde- 
termined (abdominal pain)." 

"Food poisoning" was reported on only 34 
patrols. In nine cases, the food was definitely 
incriminated; the offending agents included 
canned orange juice, canned sardines, cus- 
tard pie, beef, surveyed ''Avoset" (stabilized 
cream), chicken, tinned ham, and tinned sal- 

Food poisoning aboard an operating sub- 
marine, by incapacitating the crew, could crip- 
ple the striking force of a ship. As an example, 
a submarine sighted an enemy carrier on 10 
July and the following comment concerning 
the attack was made: 

Loss of depth on the one attack made was most 
unfortunate in that it prevented firing at carrier. The 
order to make ready ttie tubes was given rather late; 
this was combined with personnel errors in hurriedly 
preparing all tubes. At this time nearly all of the crew 
were handicapped by sickness from the food poisoning. 

Constipation was an occupational condition 
among submarine personnel. It was most com- 
mon in the first 2 weeks of a cruise. One phar- 
macist's mate during a 56-day patrol with a 
crew of approximately 75 men dispensed 3 
quarts of mineral oil, 1 pint of castor oil, 2 
pounds of Seidlitz powder, 3 bottles of cascara 
sagrada, and 20 soap suds enemas. 


The incidence of urogenital disease in sub- 
marine personnel on war patrols is presented 
in table 12. 



Table 12. — Diseases of the urogenital system in sub- 
marine personnel on war patrol 





sick days 

Goiiorrhcii, iirotlira, acvito .. 
I'retliritis acuto, iu)iiv<.'ncro:i 
Gonorrhea, \irotlira (diagnc 

sis unde- 






Prostatitis, u 1 1 « • 1 ass i fi ed 

Peiiilr lesions (diamiosis 











Renal disease ( diagnosis 





Calcidus, urinary systein„- 
Epididymitis, acute and 















One man informed the pharmacist's mate 
that he had concealed venereal disease for a 
period of at least 6 weeks, including the period 
of the last refit. Examination disclosed the 
presence of multiple penile and perineal lesions, 
which proved to be syphilitic. Kahn tests of 
the rest of the crew were negative, however. 


Most fleet-type submarines were equipped 

with two, 4-ton air-conditioning units installed 
in the ventilation supply lines. These were 
later supplemented by additional cooling and 
blower units. Without air conditioning and 
adequate ventilation, the habitability of a sub- 
marine on patrol would become so poor that 
skin diseases as well as lack of personnel en- 
durance and efficiency would appear, and the 
safety and ability of the submarine to carry 
out her mission would be seriously compro- 
mised. The following excerpts from reports of 
war patrols describe the conditions encoun- 
tered : 

"Due to faulty air-conditioning units the boat ^vas 
oppressively hot and humid . . . After 2 weeks of aU- 
day submergence all the bunks were wet and sticky. 
Clothing in lockers . . . was green with mildew. Tem- 
perature of well over 100' F. and high humidity levels 
made it practically impossible to get any rest while 
submerged. There were two cases of heat exhiaustion. 
The entire crew had prickly beat — in some it covered 
the entire body. Thirty percent . . . bad some type of 
fungus infection." Following repair of the air-condi- 
tioning system, the commanding officer commented: 
"At last we have found out that submerged time need 
not be a taste of hell— this is the first patrol that this 

boat has been anywhere near livable. General improve- 
ment in the condition of personnel and reduction of heat 
rash and skin diseases was quite noticeable in compar. 
ison with previous patrols." 

On another ship when the air conditioning 
failed ^'90 percent of the officers and men had 
^prickly heat,' 68 percent had 'Guam blisters/ 
20 percent had boils, and 12 percent had fun^^ 
gus infections of the ears." 


The health of submarine personnel was gen- 
erally very good, comparing favorably with 
that of destroyer personnel (table 13). 

Table 13. — Incidence per thousand of disease or injury 1 
of submarine personnel (19H) 







Communicable diseases transmissible by oral 

1 Exclusive of combat injuries. 

Serious illness or epidemic disease required 
the interruption of only 29 out of 1,471 patrols. 
The illnesses interfering with these patrols are 
listed in table 14. 

Table 14. — Diseases limiting duration of submarine 


Kxcrssivc IK rsoniit'I fatigue 

Illuoss of foiiiinanding ofiiccrs. 

Acute app*'iidicitis 

Battlr casualties . 

Multiple asphyxiations 

Serious injury 



Mental disease 

Copper sulfate poisoning 

Diagnosis unknown (fever) 



The factors affecting submarine habitability 
included : 

1. The efficiency of ventilating and air-conditioning j 



2 Carbon dioxide accumulation, depletion of oxygen, 
' and increased pressure and humidity. 

3. Hot weather. 

4. Overcrowding. 

5. Deficiencies of the water supply and of sanitary 

6. Fires. 

7. Noxious a^nts such as chlorine gas and carbon 

8. Material damagre incident to depth chiarging and 
accidental flooding. 

Improvement in habitability of submarines 
took place as the war progressed. As noted 
in table 15, the percentage of ''excellent'' re- 
ports was doubled after 1942 and the per- 
centage of ''poor" reports was reduced to one- 
third in the last 3 years of the war. 

Table 15. — Habitability reports of fleet-type submarines 



















N umber 











100 j 746 


Eight patrols were terminated because of 
environmental deficiencies, the nature of which 
included : 

Factor limitiniB; endurance 


f potnhh- water capacity. 
,>rrii -lis liat r»„'ry fire. 
Sorious control room tire. 
Excessive copper-salt content of drinking 

The relationship between the reports of 
"poor" habitability and the success of opera- 
tion was not explicit. In 63 submarines expe- 
riencing "poor" habitability during patrol, 39 
were successful. The majority of unsuccessful 
patrols were made in the early years of the war. 

Ventilation and air conditioning were the 
subjects of critical comment in over 400 in- 
stances. Unequal distribution of air between 
the forward and after compartments of the 
ship and inadequate cooling capacity of the 
air-conditioning units were the most common 
defects. Other criticisms concerned material 
defects of the air-conditioning apparatus in- 
volving the hazards of outboard ventilation 
in heavy weather. 

Poor living conditions often prevailed in 
cold-water operations. Metal fittings through- 
out the ship sweated constantly. Heaters had 
to be used sparingly in order to conserve the 
batteries. With sea water at temperatures of 

27° F., single-hull portions of a ship were 

impossiljle to heat. There was ice constantly 
in the torpedo room bilges, and pipes containing 
water, such as shower drains, were frozen 

The P on her fifth patrol recounted 

an experience sometimes encountered on north- 
ern operations: "The first dive made . . . lasted 
longer than expected with no carbon dioxide 
absorbent spread. At the end of 14 hours all 
hands had diflSculty in breathing, carbon diox- 
ide concentration at the time being 2.5 percent. 
Eight hundred pounds of oxygen were bled 
into the boat with slight relief. Upon surfacing 
2 hours later the concentration in the conning 
tower was 3.5 percent." 

On the fourth patrol of the N (1943) : 

"Air-conditioning installations proved inade- 
quate. The highest temperature and humidity 
level recorded was 124° F. and 98 percent 
during a period lasting about 13 hours. . . . 
Excessive heat and humidity reduced the ef- 
ficiency of all hands to a marked degree after 
about 2 weeks of operation." 


Limiting values of oxygen and carbon diox- 
ide, after submerging, were theoretically not 
attained until the expiration of a period of 
hours calculated from a formula which, al- 
though adjustable, was derived on the basis 
of peacetime complements and operating con- 



ditions. Adequate instruments to measure the 
amount of carbon dioxide and oxygen were 
not available and therefore the need for air 
purification was based on subjective evidence 
such as headache or dyspnea. When needed, 
varying amounts of carbon dioxide absorbent, 
which is caustic and irritative, w^as spread 
and the air vsras further revitalized by releasing 
oxygen or compressed air into the ship. 

On several patrols excessive levels of carbon 
dioxide seriously affected personnel efficiency. 
The fQllowing comments were made: 

The formula used for calculating the time-limiting 
values of carbon dioxide and oxygen was not always 
applicable during wartime operations; the time at 
which symptoms of intolerance became evident did not 
necessarily follow the calculated time. In 22 out of 2G 
reports, the time when the air became vitiated was from 
1 to 6 hours less than the calculated figuie. Half of 
the reports came from patrols made in Northern areas 
where, because of weather conditions and the long 
houi's of daylight, prolonged submerged operations 
were common. Moreover, the ships ^vere cold and damp, 
requiring exertion on the part of each man to keep 
warm. These factors and the increased complement 
made it necessary to revitalize the atmosphere fre- 

Air purification was a matter of particular 
concern aboard submarines used as troop trans- 
ports. "On the fifth patrol of the N , 

when 109 Army Scouts (in addition to the 
crew of 96) were transported in the Aleutian 
area, high levels of carbon dioxide were expe- 
rienced. This was particularly true when the 
Scouts were making ready to disembark. On 
the day when preparations were made to land 
the level was 4 percent." 


Sewage from the heads, washrooms, and 
galley was collected in sanitary tanks. Mili- 
tary security prevented emptying the tanks 
except upon surfacing and under cover of 
darkness. They could be flushed with sea water 
only with difficulty, and during a long patrol, 
despite frequent emptying and the use of vari- 
ous disinfectants, the tanks became mephitic. 


Toxic gases were occasionally encountered 
in submarines. Carbon tetrachloride, when used 

as a cleaning agent, produced disabling physic 

cal effects and its use was abolished. Although 
chlorine gas formation was common, especially 
after flooding of the battery compartments, 
only two instances of serious effects from 
chlorine were reported. 


In the early days of the war, the limited 
supply of fresh water was at times the cause 
for great concern and was a factor limiting 
the duration of patrols. Later, evaporating 
units capable of producing an adequate supply 
of fresh water were installed. Condensate water 
from the air-conditioning apparatus was col- 
lected and used for bathing, in washing ma^ 
chines, and for cleaning purposes. Impairmen. 
of potability of fresh water sometimes oc- 
curred. On a number of patrols contamination 
with copper sulfate took place; in one sub- 
marine the level was sufficient to endanger 
health of personnel and the patrol was ter- 


Submarines had the deserved reputation of 
serving the best food in the Navy, but the sup- 
ply of fresh meat, vegetables, and frozen foods 
was usually exhausted before the patrol was con- 
cluded. Occasionally, there occurred deficiencies 
in the quantity and variety of food because of 
unusually long patrols, inexperience in loading, 
poor quality of food, refrigeration failure, or 
accidental flooding of supplies. Considerable 
difficulty was sometimes experienced, especial- 
ly at advanced bases, in the procurement of 
some types of food. 

Typical comments in patrol reports were : 

Food was lacking in variety — a deficiency which prob- 
ably may be traced to the inexperience of comimiasary 
department personnel. 

Inexperience in planning and procurement for such 
a long patrol made the diet unsatisfactory. 

Quality of the food was good, but ran out of several 
items because of carelessness in loading. 

About 85 patrol reports mentioned having 
used vitamins, particularly for the lookouts. 
That the vitamins in submarine rations were 
ample was evidenced by the fact that only on 
two patrols, and then under the most unusual 



circumstances in the earliest months of the 
war, was there any evidence of avitamosis in 
the personnel. 
One submarine, early in the war, reported 

that an average of 1.5 pounds of meat per man 
per day had been consumed. Total food con- 
sumed averaged 5.6 pounds per man per day 
on one 47-day patrol, 31 days of which were 
spent submerged. One commanding officer was 
of the opinion that serving a light lunch at noon 
''curbed the tendency to overeat from boredom, 
with a benficial effect on the crew.'' Aboard 
another submarine, **food consumption was ob- 
served to fall off noticeably, the decline being 
most noticeable during the fourth week/' 
Others reported that the men lost their appetite 
after prolonged periods of silent running and 
depth charging. Two commanding officers re- 
ported an increase in food consumption during 
patrols in cold weather and a third reported 
that cold weather operations tripled the con- 
sumption of coffee. Cooks observed difficulty 
in baking under conditions of increased humid- 
ity within the ship, and more than one cook on 
a war patrol complained bitterly of the collapse 
of his cakes during depth charge attacks. Two 
commanding officers encouraged the crew to 
chew gum ; one of these was convinced that it 
accounted for a "noticeable reduction in the 
number of gastrointestinal comphiints usually 
observed during the course of a long patrol." 

The rations provided submarines in World 
War II succeeded in meeting the requirements 
of limited bulk, keeping qualities, and ease of 
preparation. They provided a well-balanced 
diet, a maximum of food value, and a minimum 
of waste, but a master ration plan for the sub- 
marine service, flexible enough to allow for 
satisfying individual preferences, might with 
advantage have been prepared by Submarine 
Squadron Medical Officers. In addition, thorough 
raining of the entire commissary team (com- 
missary officer, commissary steward, cooks, 
bakers, and supply officer) would have elimi- 
nated some of the problems related to the 
submarine ration. 

The one single item of food most often unfav- 
orably commented on by commanding officers 
of submarines was the large amount of boned 
beef issued. Other comments related to: 

1. The importance of ice cream in providing 

variety in the diet as well as nourishment. 
Ice cream rated high as a morale builder. 

2. The necessity of giving submarines a high 
priority in obtaining supplies of frozen 
fruits and vegetables. 

3. The importance of foods such as "Avo- 
set," canned luncheon meats, sea food, 
"Nescafe/' and jams,, particularly when 
available in small pack size in providing 
variety and enlivening what otherwise 
would have been a monotonous diet. 


Bunking facilities aboard submarines were 
designed for peacetime complements. With in- 
creased complements and the addition of new 
apparatus, space became more and more criti- 
cal, and at times serious crowding was expe- 
rienced. Adequate provisions for bunking and 
personal needs could not be made, but over- 
crowding produced no lasting effect on per- 
sonnel efficiency. 


To maintain a reasonably long and alert 
watch in the most severe weather, bridge per- 
sonnel must remain comfortable, warm, and 
dry. On cold-w^ater operations the available 
items of protective clothing were often woe- 
fully inadequate. 


Early in the war little was known regarding 
the length of time the personnel could endute 
the physical and psychologic discomforts in 
submarines on war patrols. Experience modi- 
fied some of the earlier ideas. Submarines fre- 
quently remained on station for from 40 to 50 
days, but this reduced the efficiency of the men 
and they v^ere no longer on their toes. 

A patrol carried out in good weather with 
plenty of targets, with good fire control, and 
without being subjected to depth charges, could 
last much longer than one in which these fea- 
tures were absent. The monotony of a sub- 
merged patrol without contacts was very fati- 
guing unless some change of pace or diversion 
was introduced. If lulls in activity occurred, 


material reduction in efficiency would occur or 
fatigue become apparent. Although under such 
conditions aggressiveness and desire to close 
with the enemy had not slackened, the keen 
fighting edge of the crew was definitely im- 

A high state of interest and aggressiveness 
was essential to the success of operating sub- 
marines and was closely related to personnel 
endurance and morale. The greatest single fac- 
tor contributing to high morale was successful 
engagement with the enemy for then they ceased 
to be a ''detail'' and were instead a fighting 
unit. There was nothing quite so depressing 
to the crew of a submarine with a long record 
of success as a ''zero run.'* As the war pro- 
gressed and targets became less common, the 
"lethargy of long . . . days, rough sleepless 
nights, and limited exercise had to be mitigated 
by a clear portrayal of the part submariners 
were playing in the over-all strategical and 
tactical plans." 

There were many comforts that were essen- 
tial to maintaining morale. These included 
good food, mail, movies, books, magazines, pho- 
nograph records, adequate quantities of fresh 
water, mascots, church services, favorable pub- 
licity and the possibility of a period of "State- 
side'* duty. The great importance of adequate 
and comfortable facilities to permit rest and 
recuperation for the crew at the end of patrols 
contributed greatly to the sustained pattern of 
success that characterized submarine warfare 
in World War II. - 


Submarines made approximately 1,520 war 
patrols. Of these, the missions in 1,042 were 
'^successful" and in 478 "unsuccessful." From 
these patrols 1,489 reports were available for 
study and the following conclusions were made : 
The psychic trauma sometimes experienced by 
personnel in the submarine service was as 
great, if not greater, than that experienced by 
any other group in the war. Being hunted, 
under forced inactivity in an environment of 
heat and high humidity (during the time when 
it was necessary to turn off all air conditioning 
and ventilation systems) were factors in emo- 

tional trauma. To this was added the strain of 
reconnaissance operations, mine laying, and 
days of patroling without enemy contacts. The 
caliber of leadership of the commanding officers 
was very high. There were only three instances 
in which the men lost confidence in the com- 
manding officers, or the commanding officer lost 
confidence in himself, or his ship. ^'I^ 

The following excerpts highlight some of the 
factors in emotional trauma : 

A terrific explosion jarred the boat. All hands not 
holding on to something were knocked from their feet. 
At 330 feet, fire in the manuevering room, all power 
lost. Thick toxic smoke filled the manuevering room 
and after-torpedo rooms. All hands aft were sick. We 
went up and down three times and had started down 
the fourth time before power was regained. In the 
maneuvering room the situation was bad. All hands 
were violently ill. For the first 2 hours we were in a 
mighty tough spot. Extreme discomfort was suffered 
from the accumulated heat and humidity. All hands 
stripped down to shorts and the men took off their 
shoes and socks.— The predicament of the ship was 
fully recognized by the older and more experienced 
men. As the youngsters folded up, the others took over. 
The most startling effect was the apathy engendered 
by the combination of heat, pressure, physical effort, 
and mental stress. Some without permission, others 
after requesting relief, would seek the closest clear 
space on the deck, lie down, and fall asleep. Often 
following a depth charge attack men would have nausea, 
vomiting, abdominal cramps, or diarrhea. 

Two instances of hysterical paralysis were 
reported and other manifestations of hysteria 
were observed during depth charge attack, as 
noted in the following report: 

One man got hysterical and had to be held down by 
others. One man who had made 8 previous patrols be- 
came comatose for almost 2 days during which time he 
could neither talk nor understand what was being said 
to him. He would sit upright in his bunk for hours 
with all muscles tensed and during these periods had 
difficulty in breathing. When he recovered the only 
explanation he could give was that he had a bad dream. 
Another man during the first depth charging, who had 
had previous war patrol experience in Asiatic station 
"S'' boats, broke down and later said that he had lost 
his nerve. On subsequent depth chargings this man 
proved unstable and broke down and cried on several 
occasions. . --^ . ■ 

Despite the hazards under which submarine 
crews lived and fought, the actual psychiatric 
casualty rate was amazingly low (table 16) . Out 
of 126,160 man patrols there were 62 psychiat- 



jic casualties — ^an incidence of 0.00041 per 
man patrol. 

Table 16. — Psychiatric vassal ties encountered aboard 



PsychoneuroBifc, anxiety 

Psychoneurosis, hysteria.. . 
Psychoneurosis, unclassified 

psychosis, unclassified 

Neuritis, unclassified- 

Paralysis, unclassified 

Paralysis, facial nerve 

Epilepsy — 

Migraine... --.---r-" 

Diagnosis undetermined: 

Syncope — . 



Number of 
patrols reporting 

Number of 
cases reported 



This low rate is probably attributable to the 
following: (1) Careful selection of personnel, 

(2) thoroug-h and specialized training, (3) high 
morale associated with success of combat sub- 
marines, (4) adequate rest and rehabilitation 
facilities and frequent rotation of duty, and (5) 
medical examinations before and after patrol 

found to be of great importance. Under pre- 

war conditions some of the requirements for 
selection of personnel for submarine duty were 
automatically covered by the performance of 
satisfactory duty afloat for 3 years. This auto- 
matic screening became inoperative when large 
numbers of personnel were received fresh from 
civilian life. The rapid influx required the modi- 
fication of some of the physical requirements 
for enlistment — notably those of the teeth. Den- 
tal officers unfamiliar with the necessities of 
the submarine service had been rejecting al- 
most 50 percent of the candidates because of 
slight underbite or overbite or missing incisors, 
because of the erroneous concept that the 
mouthpiece of the submarine escape appliance, 
the ''lung/' must be gripped firmly with the 
teeth. (The mouthpiece is gripped with the lips, 
primarily.) As a matter of fact the dental re- 
quirements for duty in submarines could be 
met, in the absence of marked overbite or un- 
derbite which made lip gripping of the mouth- 
piece difficult, if the applicant had suflScient 
number of opposing teeth for biting and masti- 


In nearly 4 years of war, only 62 deaths 
from all causes (including battle injuries) oc- 
curred aboard submarines on patrol (table 17) . 

Table 17. — Deaths occurring aboard submarines on 
war patrols 

Cause of death 

Number of men 

Patrols reporting 





Drowned — ^lost over the side 

Killed— battle injuriefl, 

Killed — accidental 

Suicide. _ 














At the onset of the war, the only physical 
examination of personnel prior to assignment 
to duty in submarines was that prescribed in 
the Manual of the Medical Department (1939). 
Intelligence quotient and psychological fitness 
Were not considered. These factors were later 


Testing night vision became necessary in 
order to properly select night lookouts, or at 
least eliminate the night-blind. The first work 
on this problem began in April 1941 and was 
continued and greatly expanded during the 
war. The experimental phase was carried out 
at the Medical Research Laboratory, Sub- 
marine Base, New London, Conn. 

Submarine personnel were also tested for 
their visual acuity as radar operators. Require- 
ments were found to be normal near-vision acu- 
ity and normal photometric measurements. 


One of the most important contributions 
made by the Submarine Force was the early 
development and application of selection pro- 
cedures for sonar operators. The pioneer work 
of the staff of the Medical Research Laboratory 
of New London, formed the basis for the prd- 
cedures developed for the selection of sonar 
operators for Fleet units. 




Psychologic testing (using paper-and-pencil 
test) was used extensively in the selection of 
personnel for submarine duty. The early impe- 
tus for the development and application of 
these tests came from civilian research groups, 
such as the NDR Committee of Brown Univer- 
sity Division. Many of these tests proved to be 
of great value in eliminating psychologically 
unfit personnel. 

The submarine service became interested in 
intelligence tests early in 1942. This was nec- 
essary in order to assure the selection of per- 
sons of average or above average intelligence 
for submarine duty. In the beginning, however, 
selection interviews were conducted by Medical 
and Hospital Corps personnel who were not 
trained in psychiatry. The psychiatric selection 
interview by a psychiatrist with the Medical 
Examining group at New London was insti- 
tuted in 1943. The combination of paper-and- 
pencil tests and psychiatric interview was em- 
ployed. At first psychiatrists at the training 
centers had to interview as many as 20 to 30 
men per hour throughout the day. This obvious- 
ly was not only impracticable, but practically 
impossible. Much more effective service was 
rendered by using the paper-and-pencil psycho- 
logical test for the original screening, and re- 
ferring only those in the "failing" or "doubt- 
ful" categories to the psychiatrist. 

In 1943, an "Interview Board'' was estab- 
lished. This Board consisted of a representa- 
tive of the staff of Commander Submarines, 
Atlantic Fleet, a representative of the sub- 
marine personnel division of Bureau of Person- 
nel, and a medical representative from the staff 
of the Medical Research Laboratory at New 
London. These Boards traveled to various offi- 
cer indoctrination units, where in cooperation 
with the medical departments they studied the 
records of the volunteers for submarine duty 
and interviewed the likely candidates. After 
this interview system was established, men 
selected for submarine duty were found to be 
much more likely to pass the detailed and rigid 
examinations than had been the case when 
groups of unscreened volunteers were selected. 
Many man-hours were thus saved and much 

disappointment and resentment in personnell 
was spared. Previously, candidates had bee] 
selected at one station and after traveling 
another activity and being interviewed haj 
often been found not qualified. 

Personnel selection procedures at first did 
not always function well. Frequently selection 
officers failed to work together or did not kno^ 
the part played by others in the selection sys. 
tem. Physical examinations were often done 
by untrained personnel, and examining facilu 
ties w^ere lacking or inadequate in many in; 
stances. In fact, the situations encountered led 
one to wonder how anyone was properly se- 
lected for submarine duty. When a statistical 
accounting system was set up in 1944 
complete monthly reports of selection results 
were forwarded to all stations furnishing can- 
didates, the efficiency in personnel selection im- 
proved to a great extent. 

A representative of the submarine medical 
examining section of the Submarine Base, Ne^v 
London, visited activities throughout the 
United States and held indoctrination confer- 
ences with the classification and selection offl. 
cers. Following these conferences, the type of 
men selected for submarine duty consistently 
improved and attrition dropped as much as 
75 percent. 

The Submarine Escape Training Tank was 
used by the selection group at New London to 
identify the emotionally unstable and psychiat- 
rically unfit candidates. It was assumed, and 
at least partially established, that men who 
failed in the adjustment necessary for proper 
performance during lung training would be un- 
likely to make the adjustment essential for duty 
in a submarine. 


The submarine service was the first in the 
U.S. Navy to inaugurate night lookout train 
ing. This training was developed under the aus- 
pices of the Medical Research Unit at Subma 
rine Base, New London, Conn. Following 
receipt of reports from the British concerning 
the importance of such training in lookouts, 
the Commander Submarines, Atlantic Fleet 
became interested in the possibilities of thi^ 


training for the submarine service and a night- 
lookout training table similar to that used by 
the British was set up in 1941. From the be- 
ginning, commanding officers were enthusiastic 
about this training, and the program was very 
popular with men. 

The original trainer provided by varying 
lighting effects a reasonably realistic horizon 
simulating that at sea. A greatly improved 
version of the "Lookout Stage," embodying 
several improvements, was constructed early 
in October 1942. Similar stages of a ''portable" 
type were constructed and distributed through- 
out the Navy for the training of all personnel. 
These had a realistic horizon, and moonlight, 
recognition lights, and sounds of distant gun- 
fire could be simulated. Its advantages as a 
training device lay in its realism and the inter- 
est which it aroused in the student. Its value 
in indoctrination and preliminary training of 
beginners was unquestioned. 

In March 1943, the Commander, Submarine 
Force, recommended the establishment of the 
Renshaw Recognition Trainer at submarine 
activities. This training, which was modified to 
fit submarine service needs, was included as a 
part of the night-lookout training program al- 
ready in operation at the Submarine Base, New 
London. As the work in night visual, general 
lookout, and recognition training began to in- 
crease, it was obvious that a lookout school 
should be organized. This was established in 
February 1944. Later the Bureau of Personnel 
established lookout training schools in conjunc- 
tion with recognition training at all training 

Officers assigned as instructors in these 
schools were given additional training in look- 
out work at the Medical Research Department, 
Submarine Base, New London, in order to 
enable them to train men in either basic train- 
ing schools or in "L" divisions aboard ships. 
A course in lookout procedures had been added 
to the curriculum of the Naval Training School 
(Recognition) at Ohio State University early 
in July 1943. This obviated the need for trans- 
ferring graduates to New London for addition- 
al instruction. 


On 1 May 1944, the Bureau of Personnel 
authorized the establishment of Telephone 
Talker Schools in all Class A, B, and C Schools, 
and assigned the operation to the Medical Re^ 
search Department. Later the name of this 
school was changed to ' 'Interior Voice Com- 
munication School." 

It was found necessary to give training in 

the following: 

1. How to increase intelligibility when 
using communication instruments. 

2. How to formulate brief, efficient orders, 
and report the execution of orders. 

3. How to efficiently operate and handle 
voice transmitting equipment. 

4. The use of standard phraseology and 
procedures for interior communica- 

5. Organization of sound-powered and 
broadcasting circuits under various 
battle and operational conditions. 

6. Standard terminology for use on sta- 
tions or submarines. 

The following manuals were used in training : 

1. "Submarine Telephone Talkers' Man- 

2. ''Suggested Ship's Organization : ''Chap- 
ter on Interior Voice Communications 
of fleet type submarines." 

3. "Standard Submarine Phraseology." 

4. "Standard Submarine Phraseology and 

5. "Instructors Handbook for Instruction 
in Submarine Interior Voice Commun- 

One of the most important parts of the train- 
ing program was teaching the use of standard 
procedures. A practical drill was developed that 
greatly facilitated instruction in voice com- 
munication procedures, phraseology, and ter- 
minology for the submarine crew. Scripts of 
orders and messages were used to force the 
student to utilize correct procedures, phraseolo- 
gy, and terminology, while simulating actual 
submarine operations. 




In 1980 a submarine escape training tank 
was put into operation to permit the thorough 
training of all submarine personnel in the use 
of the "lung" under conditions that exist dur- 
ing an actual escape from a disal)led submarine. 
All submarines were equipped with this escape 
apparatus. With the advent of World War II, 
'lung" training facilities were expanded, in 
order to handle the large numbers of men enter- 
ing the submarine service. In spite of a great 
expansion in such facilities, many men who 
entered the submarine service at advanced 
bases did not receive "lung" training. 

Although it was considered unlikely that the 
''lung'' would be used for escape in wartime 
disasters, training in its use was continued 
throughout the war for the following reasons : 
(a) It was considered to be an excellent morale 
factor, (b) it gave a sense of security and com- 
fort to the families of the men, and ( c) it was 
used by the Medical Research Department of 
the Submarine Base, New London, Conn., in 
their selection program as a means of eliminat- 
ing the emotionally unstable. Men who became 
excessively nervous during the training were 
disqualified for submarine duty oil the grounds 
of emotional instability. If they ''could not 
take" "lung" training, what could be expected 
when the depth charges were rolling? The 
"lung" was used by the men of one disabled 
submarine for a very dramatic escape, and the 
training given at New London enabled two of 
the men to make successful "free escape" with- 
out a "lung." 

In order to escape from a sunken submarine, 
it is necessary to raise the pressure within a 
compartment of the ship from which egress 
is to be attempted, until it equals the outside 

water pressure. To do this, the compartment isS 
flooded by admitting water. As the water rises/^ 
it compresses the air in the upper part of the' 
compartment. When the water has risen to the 
top of the escape door, a hatch can be opened 
by hand and a buoy with an ascending line re* 
leased through the hatch. Escape to the surfaci 
is made with the use of the lung. 

Escape tank training included the following: 
(a) A pressure test of 50 pounds per squard 
inch in the decompression chamber ; (/)) a lee 
ture on construction, operation, safety features, 
and precautions in use of the lung; (c) shallow 
water training for confidence in breathing 
under water; (d) 12-foot training to attain 
proper relaxation and confidence; and (e) 18- 
and 50-foot training to permit the student to 
become skilled in the use of the lung so that 
should he be called upon to use this device to 
save his life, he would have no doubt as to its 
lifesaving qualities. 

The number of men trained and qualified in 
"lung" escape is noted in table 18. 

Table 18. Number of men trained and qualified in 

'Hung** escape 

Fiscal year 






1934 35 


1936- 37 

1937- 38 

1938 39 

1939- 40 

1940- 41 

1941 12 

1942- 43 

1943- 44 

1944- 45 




12, .590 
















The Dental Situation 

On 7 December 1941 there were 759 dental 
officers (including 369 Reserves on active duty) 
to provide dental care for a combined Navy, 
Marine Corps, and Coast Guard of about 486, 
000 men. Three hundred and forty-seven dental 
facilities were in operation. These varied in 
size from the one-dental-officer clinic at the 

smaller stations to such large, superbly 
equipped dental clinics as that at the U. S. 
Naval Training Station, Great Lakes, 111., 
which had 155 dental officers on duty. 

After 4 years of war, on 14 August 1945, 
7,026 dental officers (including 6,457 Reserves) 
were on active duty. They provided dental care 




for a Navy of about 4 million men and women. 
Of these there were 4,470 dental officers in the 

continental United States, 1,350 at foreign sta- 
tions, and 1,206 afloat. There were 1,545 dental 
clinics in operation at Naval and Marine activ- 
ities throughout the world, ashore and afloat. 
These stations included those listed in table 19. 

TABLE 19. — Dental facilities as of August 1H5 

Type activity 


Operating bases 

Bepair bases.- 

Construction battalions 


Supply depots ------ 

District dental orhcers 

Naval hospitals 

Dental schools 

Pro-flight schools 

Air stations 

Train iiiK renters 

V-IL' units 

Navy yards 


Afloat: . 

Fleet hospitals 

Naval ships: 







Transport for wounded 

Tank and repair 

Transport attack 

Carpo attack 


Amphibious forces: 

Base hospitals 

Amphibious training centers. 

Marine a: 















Dental officer 


3- 53 

1 1 

4- 23 



1 I 
1 3 
» 1 
1 1 
» 1 









1 1 

1 Each. 


About 1,000 dental technicians were on 
active duty at the outbreak of World War IT. 
On 14 August 1945, 44 Dental Repairmen, 2,142 
Dental Prosthetic Technicians, and 8,153 Dental 
Technicians, General, were on duty. Of these 
more than 1,200 were WAVES. 

Generally, dental technicians were trained 
in the Navy; however, because of the need for 
experienced dental prosthetic technicians a 
number of qualified technicians from civilian 
life were rated as Pharmacist's Mates, Dental 
Technicians, Prosthetic, upon enlistment. (Bu- 
reau of Naval Personnel directive of March 

Prior to 7 November 1941, the course of in- 
struction given at the Naval Dental School, 
Bethesda, Md., for Dental Technicians, Gen- 
eral, was of 4 months' duration. A 5 months' 
course for Dental Technicians, Prosthetic, was 
given at all naval dental prosthetic activities. 
All ratings were eligible for the General Tech- 
nician course, but only PhMlc, PhM2c, and 
PhM3c were eligible for the Prosthetic Tech- 
nician course. In November 1941 these courses 
were shortened to 10 weeks for the General and 
to 4 months for the Prosthetic, and HAlc was 
also included in the ratings eligible for the 
General course. At this time the latter course 
was given only at designated naval training 
centers and at the Naval Dental School, Be- 
thesda, Md. In January 1945, 102 naval dental 
clinics were also designated to train hospital 
corpsmen in dental specialties. 

With the great increase in the size and num- 
ber of dental clinics, maintenance and repair 
of dental equipment became a problem. To meet 
this need enlisted men had to be trained in such 
maintenance and repair work. A Dental Main- 
tenance and Repair School, the first of its kind 
in the Navy, was established at the U. S. Naval 
Training Center, Bainbridge, Md., on 25 Peb- 
rivdYx 1945. Men completing this course were 
rated Dental Technician, Repair. 

The peacetime dental standards for enlist- 
ment in the Navy established a i-equirement of 
at least 20 serviceable teeth; four opposing 
molars (tw^o on each side), and four opposing 
incisors (two on each side). Gingival diseases, 
carious teeth, oral tumors, extensive periodon- 
tal disease, malocclusion, and wide edentulous 
spaces in either the maxillary or mandibular 
arches were considered disqualifying. These 
standards were rigidly applied in the cases of 
officer appointments, and in enlistments for 
aviation and submarine duty. 

The reason for specifying 20 serviceable 
teeth, and the presence of opposing molars and 
incisors, was to reduce workload and costs, if 
subsequent prosthetic restorations were re- 

Application of the peacetime dental stand- 
ards resulted in the rejection of 1 out of every 
5 selectees for the Army in 1941. In that same 
year, out of 340,000 applicants for the Navy, 



7.8 percent were rejected for dental defects. 
The percentage of men with disqualifying den- 
tal defects was probably higher than that 
recorded, because in many instances, if a man 
was found physically disqualified, a dental ex- 
amination was not conducted. 

Because so many applicants could not meet 
the peacetime dental standards, the Bureau of 
Personnel and U. S. Marine Corps Headquarters 
jointly modified the dental requirements, speci- 
fying 18 serviceable teeth instead of 20, two op- 
posing molars instead of 4, and not more than 4 
missing incisors satisfactorily replaced. A cari- 
ous tooth which could be restored by fillings was 
considered a serviceable tooth. Applicants wdth 
extensive dental infection, or who required 
immediate prosthetic oi* orthodontic treatment, 
however, were still not accepted for the services. 

On 29 May 1948 the Bureau of Medicine and 
Surgery low^ered the dental requirements so 
as to agree with the mobilization requirements 
of the Army. Only severe and irreparable den- 
tal defects were to be considered as disqualify- 
ing for inductees. Edentulous upper and/or 
lower arches, corrected or correctible by den- 
tures, and malocclusion not interfering with 
minimum mastication and not resulting in 
pathologic dental changes were not considered 


The lowering of dental standards marked the 
start of a vast dental rehabilitation program. 
To provide the necessary facilities, 97 dental 
activities were designated in October 1943 to 
give dental prosthetic treatment. Such treat- 
ment, without prior approval of the Bureau of 
Medicine and Surgery, was authorized, and 
dental prosthesis became the responsibility of 
the cognizant dental ofTicer. Previously, pros- 
thetic treatment without prior Bureau approval 
had been permitted only for personnel on sea 
duty or for those outside the continental United 

This dental rehabilitation program attempted 
to make all Navy and Marine Corps per- 
sonnel dentally fit, regardless of their den- 
tal condition. It was an extremely difficult as- 
signment for the Dental Department because 
enlisted men were to be considered not physic- 
ally qualified for transfer beyond the continen- 

tal United States if they required prosthetic 
dental treatment. Later in the war, no person* 
nel were to be considered qualified for duty 
overseas, until all dental treatment (operative 
and prosthetic) was completed. The responsi- 
bility for carrying out such treatment rested 
with the dental clinics at the naval training 
centers and at ports of embarkation. Dentay^ 
treatment was given to personnel of the UnitedH 
Nations eligible for lend-lease aid, when they 
could not obtain adequate dental care other- 
wise, and to Army personnel in areas where 
no Army dental facilities w^ere available. 

Examples of the work accomplished during 
the war are the following : 

29,654,343 restorations of all kinds 

509,292 dentures— all types 

27,232 bridges — all types 

4,229,809 teeth extracted 
In 1942, 646 fractures of the jaw were treated, 
570 of them mandibular. In 1943, the total was 
3,096, of which 2,780 involved the mandible 
and 316 the maxilla. In 1945, the grand total 
reached 4,355, including 3,304 mandibular, 409 
maxillofacial, and 642 maxillary. 



The problem of obtaining dental supplies and^ 
equipment at the beginning of the war was 
acute. Facilities and equipment for dental^ 
treatment were not available to meet the in-" 
creased needs. In lieu of new dental burs, used 
burs w^ere saved, cleaned, oiled, and sent to the 
U. S. Naval Medical Supply Depot, Brooklyn, 
N. Y., for resharpening and reissue. By Octo- 
ber 1942 the dental bur supply was further cur- 
tailed. Only certain angle and straight hand- 
piece burs could be manufactured and of these 
only a limited quantity was produced. Because 
of the curtailment in supplies, dental facilities 
in continental United States could requisition 
supplies on a 3-month minimum, 6-month max- 
imum basis. This held true throughout the war. 

In December 1942 the Bureau directed con- 
servation of all critical materials. These in- 
cluded amalgam scrap, precious-metal bench 
sweepings and trimmings, and polishing resi- 

The equipment for dental clinics at the var-j 
ious advanced bases was standardized, depend- 1 



ing UP^^"^ medical components of the base. 
The Dental Branch of the War Plans Section 
determined the dental materiel and personnel 
needs for each advanced base and specified the 
standard equipment. When dental components 
were required for an advanced base, commen- 
surate dental personnel and equipment could 
be readily ordered. 

Because of the shortage of dental equipment, 
a "shift'' system was devised to keep available 
dental equipment in service 12 to 16 hours a 
day. This was particularly necessary at the 
larger training centers and navy yard dispen- 
saries. In December 1945 this system v^as dis- 
continued, because with demobilization in prog- 
ress, personnel and equipment were in excess 
of immediate needs. 

New types of dental facilities were built dur- 
ing the war. To provide dental treatment for 
small groups of naval personnel at isolated 
stations and at training schools, nine self-con- 
tained mobile dental operating units and one 
mobile dental prosthetic unit were built. The 
first mobile unit was placed in operation in the 
Eighth Naval District on 18 February 1945. 
The construction of 'Vlental clinic ships'' was 
recommended by Commander, Service Forces, 
Pacific Fleet, in June 1945, and construction 
of four such ships was authorized in August 
1945. With the cessation of hostilities, however, 
this plan was abandoned. 


Prior to November 1941 dental officers had 
been assigned to civilian educational institu- 
tions, as well as to the Naval Dental School, 
Bethesda, Md., for postgraduate instruction in 
oral surgery and prosthodontia. During the war 
the number of short postgraduate courses in 
oral surgery at these activities was increased 
and a course in ocular prosthesis was added to 
the curriculum at the Naval Dental School. 

On 1 January 1942 the Surgeon General 
directed all dental officers to become proficient 
in the administration of first aid, treatment of 
burns, shock, and hemorrhage, disposal of the 
dead, and other duties related to the Medical 
Department, in order to assist the medical offi- 
cers when occasion demanded. Aboard ship, 
dental officers also assisted medical officers in 

teaching first aid to the ship's company. First- 
aid training was made available to all dental 
officers, at naval hospitals, naval training cen- 
ters, and at the Naval Dental School. 


A number of organizational changes were 
made in the Dental Division of the Bureau dur- 
ing the war. On 16 October 1942 the Surgeon 
General established offices of district dental 
officers. Although some of the larger naval dis- 
tricts then had a District Dental Officer, it be- 
came necessary to assign a dental officer to each 
naval district to coordinate dental activities* 
This officer was to advise the Commandant and 
the Bureau regarding dental installations and 
assignments of personnel within the district, 
and to make reports to the Bureau and the 

A reorganization of the Dental Division was 
directed by the Surgeon General on 8 February 
1943. This charged the Dental Division with 
''cognizance of professional standards for den- 
tal practice in the Medical Department/' with 
conducting "inspections and surveys for main- 
tenance of such standards/' and with advising 
the Bureau on expansion of dental facilities, 
on Dental Corps personnel, on dental equipment 
and supplies, and on special authorizations for 
dental treatment. In order to carry out these 
functions, the Dental Division was divided into 
a Standards Section and an Inspections Section. 
The former had cognizance of professional 
standards; the latter was to conduct inspec- 
tions and surveys for maintenance of estab- 
lished standards. 

A Force Dental Otticer was assigned to the 
staff of Commander South Pacific Forces on 
1 June 1943. 

The Office of Fleet Dental Officer was estab- 
lished in the Fleet on 17 January 1944 and on 
the Staff of CincPAC-CinPOA in December 

In 1944 a Dental Section was established in 
the Headquarters and Service Company of the 
Medical Battalion of Marine Divisions of the 
Fleet Marine Force, with the senior dental offi- 
cer acting as Division Dental Officer. 



On 18 September 1944, the Dental Division 
of the Bureau was again reorganized. The 
Dentistry Division was directed to "study, 
evaluate, advise, and make recommendations 
on the dentistry needs, policies, standards, 
practices, and performances of dental activi- 
ties in the Medical Department;'' to make 
recommendations ^'pertaining to complements, 
appointment, promotion, advancement, train- 
ing, assignment, and transfer of dental per- 
sonnel;'' and to ^'maintain liaison with such 
other BuMed offices or divisions or such other 
military and civilian agencies as may be re- 
quired." An Office of the Chief of Division, a 
Dental Standards Branch, and a Dental Per- 
sonnel Branch were set up to carry out the 
directive. The Chief of the Division was held 
responsible for the performance of all func- 
tions assigned to the Dentistry Division, and 
was directed not to adopt ''major policies, 
methods, or procedures without the approval 
of the Chief of the Bureau of Medicine and 

Other changes of interest in the Dental 

Corps included the following : Capt. Alexander 
Gordon Lyle (DC) USN was nominated in 
March 1943, as the first Rear Admiral in the 
Dental Corps. The first woman dentist to be 
commissioned was Lt. Sara S. Krout (DC) 
USNR, WAVES. She reported to the U. S. 
Naval Training Center, Great Lakes, 111., in 
June 1944. The first woman Dental Hygienist 
to be commissioned was Ensign Jessie Rath- 
bone, USNR, WAVES. The Office of Inspector 
of Dental Activities and the Office of the As- 
sistant for Dentistry were established in the 
Bureau of Medicine and Surgery on 18 Sep- 
tember 1944 and 24 May 1945, respectively. 


Dental research had been carried on under 
the cognizance of the Naval Dental School for 
many years prior to World War II. During the 
war, research was accelerated and was closely 
coordinated with that of the Medical Depart- 
ment. As a result, valuable contributions were 
made to both medicine and dentistry. Of par- 
ticular importance was the Dental Depart- 
ment's participation in rehabilitation. The re- 
sults of the research project ''Esthetic and 
Functional Hand and Digit Prosthesis and Eye 

Prosthesis," which was started 11 May 1945, 
made possible the development of prosthetic 
devices for the amputee and the acrylic eye 
for the blind. Other dental research includedJ 
the following: i 

1. **Efficacy of penicillin in the treatment of j 
oral fusospirochetosis." This was the firstil 
attempt in the Navy to determine a 
method whereby large numbers of meiii 
could be treated quickly and still be kepll 
at their duties. 

2. *'Study of occurrence of caries in thej 
same surfaces bilaterally and/or ad-i 

3. *Tresence of Vincent's organisms in the 
mouth of patients being treated for - 
syphilis." | 

4. "A portable dental operating light fori 
field use.'' ] 

5. "Effect of methyl methacrylate fillings on] 
pulp tissue of dogs" (study incom-l 
pleted) . 

6. ''Relationship of dental occlusion to ear 
block" (carried out in the low-pressurel 

chamber) . 

7. "Results of dental therapy in 50 cases of 
aerotitis media in submarine personnel! 
based upon a new functional concept of 
eustacian tube blockage." 

8. "A rapid dental treatment for the pre- 
vention of aerotitis media." \ 

9. "Evaluation of a concept of dental treat- 
ment based on a functional classification 
of malocclusion." | 

10. "Dental treatment of trismus, tinnitus,; 
otalgia, and obscure neuralgia." 


The following observations were made by 
dental officers on duty in the various theaters 
of war: 

1. "Insufficient prosthetic facilities were 

available in the forward areas. The 
trailer or truck type operating units 
would have been a solution had they been 
developed soon enough." 

2. **Dental officers with administrative and 
organizational ability as well as battle 



experience should be in charge of den- 
tal facilities in forward areas or large 
dental activities/' 

3. ''Dental officer personnel fresh from civili- 
an practice with little or no experience in 
handling officer and enlisted personnel 
should not be in charge of large dental 

4. "The hurried and selective form of den- 
tistry, although objectionable, was the 
only solution during wartime/' 

5. ''During the war it was absolutely neces- 
sary for medical and dental personnel to 
function as a unit rather than as separ- 
ate entities/' 

6. "Maxillofacial teams made up of medical 
and dental officers and corpsmen were 
needed to efficiently treat the large num- 
ber of patients with head and neck in- 

7. *'There was a need in the Dental Corps 
for enlisted personnel with stenographic 
and bookkeeping expei ience to handle rec- 
ords more intelligently and efficiently and 
to maintain files according to standards/' 

8. "The clinical and instructional phases of 
naval dentistry at those activities where 
instruction was given should have been 
separated to a greater degree. To obtain 
competent naval dental instructors, a 
number of dental officers should be 

trained in this field/' 

9. "There was a need for a large Reserve 
dental officer group trained in military 

dentistry. The time required by Reserve 
officers to make adjustments during war 
and the resultant discontent and misun- 
derstanding might have been avoided to 
a large extent had a more active Reserve 
training program during peacetime been 

10. ''Regular rotation of duty between con- 
tinental United States and extraconti- 
nental stations ashore and afloat should 
be stressed during time of war. When 
this was initiated in the Pacific, morale 
among dental officers was considerably 
improved. A 1-year tour of duty in an 
active battle area was considered suffi- 

11. **Air conditioning was a necessity in 
ships' dental offices in the Tropics. In 
such environment, perspiration of the 
hands caused slipping of dental hand- 
pieces and instruments, and soft tissue 
injury occurred on several occasions be- 
cause of this/^ 

12. **A small prosthetic outfit should be avail- 
able aboard all ships for emergency den- 
tal prosthetic service. This should include 
a small acrylic outfit to quickly construct 
acrylic crowns/' 

Chapter II 

Experiences in Battle of the Medical Department 

of the Navy 

Joseph L. Schwartz, Captain (MC) USN (Retired) 

Pearl Harbor 

At about 0800 on 7 December 1941, the first 
wave of aircraft from a powerful Japanese 
force attacked the United States Naval Base, 
Pearl Harbor, T.H. (figs. 66, 67, 68). Maga- 
zines in ships exploded, burning fuel oil cov- 
— ered the water, fuel dumps went up in 
flames, buildings and I'unways were struck by 
bombs, aircraft were destroyed before they 
could take to the air, and military personnel 
and civilians were strafed by machinegun fire 
as they sought cover on the ground. Even as 
the attack was still in progress, trained medical 
units of the Navy, ashore and afloat, went into 
action to collect and care for the large num- 
bers of casualties. 

Figure 66. — Disaster at Pearl Harbor. 




Figure 68. — Disaster at Pearl Harbor. 

At the Naval Hospital at Pearl Harbor ail 
treatment and operating-room facilities were 
set up and ready for use by 0815. Within 10 
minutes after the attack began, casualties were 
arriving at the hospital, and in the first 3 
hours approximately 250 patients had been ad- 
mitted and treated. Altogether 546 patients 
and 313 dead were brought to the hospital that 
day. In addition, more than 200 ambulatory 
patients were treated and returned to their 
duty stations. By midnight of 7 December, 
the hospital patient census was 960. 

Despite the large number of patients and 
the great variety of injuries treated, the sup- 
plies at the hospital were sufficient to meet 
the unprecedented demand, shortages appear- 
ing only in stores of plasma and tannic acid, 
which became depleted in the treatment of the 
large numbers of patients who had been 
burned. Some 60 percent of all patients ad- 
mitted had clinically significant burns, in many 
cases the result of exposure to the flash of 
ignited gasoline or high explosive. Every con- 
ceivable type of wound and injury was ob- 
served, including a number of bizarre trau- 
matic amputations. Although treatment of 
burns was left to the discretion of the indi- 
vidual medical officer, tanning agents were 
used in most , cases, and variations occurred 
only in the agent selected, principally tannic 
acid, picric acid, gentian violet, triple dye, and 
silver nitrate. A few received wet saline dress- 
ings, sulfanilamide in mineral oil, or simply 
a heat cradle. Although many patients had 
been in the water and were covered with fuel 

oil, the large case load precluded any attemp] 
at removal of the oil before treatment wai 
instituted. It was noted subsequently, that the 
presence of oil on the burned areas did not 
impair the efficiency of treatment and healing 
progressed in the same fashion as if the oil ha^ 
not been present. 

Compound fractures were debrided and 
sulfanilamide powder was sprinkled in thef 
wound; a plaster of paris cast was then ap- 
plied, after which a roentgenogram was made 
and the position of the fragments was out- 
lined on the cast with indelible pencil. This 
method of marking the position of the frag- 
ments provided invaluable information to the 
medical officer subsequently treating the pa- 
tient. Sulfonamides w^ere also adminiistered 
orally for from 4 to 10 days after the initial 
treatment. The absence of infection in wounds 
of patients so treated proved those agents to 
be of value in combating infection, and it was 
shown that with early use of these drugs the 
time between injury and initial surgical treat- i 
ment could be extended, when necessary, be- 1 
yond the first 6-hour period. j 

A record of the patients admitted could not 
be kept at first because of the urgency for 
treatment and the very rapid rate of admis-| 
sion. Later, when it became possible to record 
admission data, identification was often de-. 
layed, for none of the patients wore identifi-| 
cation tags and in many cases clothing was 
marked with several names. The Naval Hos- 
pital at Pearl Harbor, staffed by 41 medical 





54 nurses, and 331 enlisted men, 

ted more than 6,200 inpatients during 


The hospital ship Solace, anchored in Pearl 
Harbor, was unharmed by the attack. By 0825, 
when the first patients began arriving, all 
was in readiness to receive a large number of 
casualties, which at the end of the day 
amounted to 132 admissions in addition to 
about 80 ambulatory patients who were treated 
Ind returned to their duty stations (fig. 69). 
The Solace received the Commendation Award 
from Admiral Nimitz for professional skill and 
devotion to duty. 

Because of the large number of fleet units in 
the Hawaiian area and the need for additional 
hospital facilities there, the U. S. Mobile Base 
Hospital No. 2, w^as shipped to Pearl Harbor 
in November. This unit landed just 12 days 
before the Pearl Harbor attack, but had not 
yet been erected. Only the crew's quarters 
were up. Because of the experience in the erec- 
tion of its prototype. Mobile Base Hospital 
No. 1, in Guantanamo Bay, Cuba, in the pre- 
vious year, the packing and marking of the 
supplies and equipment and the arrangements 
for uncrating supplies for this hospital were 
so efficient that it was possible to break out 
needed items on short notice. As a result, even 



though U. S. Naval Mobile Hospital No. 2 ex- 
isted only in crates, it provided personnel, sup- 
plies, and equipment to care for and treat 110 
patients on 7 December. For this fine work, the 
Medical Officer in Command, Capt. William 
Chambers (MC) USN received the Distin- 
guished Service Medal Mobile Hospital No. 2 
continued to operate throughout 1942 and was 
decommissioned in 1943. 

Immediately after the attack the medical 
departments of the First and Third Defense 
Battalions at Pearl Harbor jointly established 
3 dressing vStations and within 3 hours had also 
outfitted a collecting and casualty dressing 
station and were treating patients from tmits 
of the Fleet. 

The Naval Hospital at Aiea Heights, under 
construction at the time the attack occurred, 
did not admit patients until 12 November 1943. 
(During 1944 this hospital admitted 42,721 
patients, of whom 5,256 were from Saipan and 
2,848 from Guam and Tinian. On one day (3 
July 1944) 1,169 patients were admitted.) 

Medical Department personnel in fleet units 
at Pearl Harbor required no alert when enemy 
bombs and torpedoes struck ships anchored at 
Pearl Harbor. Even as bomb and torpedo 
bursts wreaked havoc in the Arizona, West 

Figure 69. — Patients being treated for shock aboard the U.S.S. Solace. 



Figure 70.— Survivors after rescue at sea— sickbay of PCE (R) 851. 

Virginia, Maryland^ California, and other 
ships in the harbor, battle dressing stations 
were manned and the injured were treated 
promptly and effectively. The competence of 
the Medical Department personnel in first aid 
was, in many respects, equalled by that of the 
crew. Because of previous instructions and 
drills in first aid and transportation of the 
wounded, they rendered lifesaving service to 
their injured shipmates. The efficiency in 

treatment was not a matter of type or si) 
of ship. It was of the highest order whether 
carried out in a battleship or destroyer (fig 

The prompt and efficient manner of prepar- 
ing for the treatment and evacuation of pa- 
tients under fire, and the bravery and resource 
fulness of Medical Department personnel ii 
shore-based and fleet units attested to their 
high state of preparedness and training. 

The Solomons Campaign 

The early months of 1942 were fraught with 
disaster for the Allies in the Pacific theater, 
as in other parts of the world. Corregidor's 
valiant garrison had finally surrendered, 
Singapore had fallen, and landings had been 
made by a small force of Japanese in Western 
New Guinea, with the aim of taking Port 
Moresby, cutting our supply line to Australia, 
and bringing that continent under attack. In 
the last days of April 1942 a powerful Japa- 
nese naval force was reported entering the 
Coral Sea and all available American and Aus- 
tralian naval might was concentrated to meet 

this threat. The force consisted of warship 
and transports containing some thousands of 
troops for a landing in Papua. The memorable 
Battle of the Coral Sea, while costly to us in 
the loss of the aircraft carrier Lexington, wa.- 
an important strategic naval victory in that 
the Rising Sun was effectively turned back 
from its mission. | 
A few weeks later, the Japanese sent an 
even mightier force to take Midway. Our own 
forces, at the cost of the aircraft carrier York- 
town, aborted the attack and routed the enemy 



These victories, however, provided only a 
•ief respite, for the Japanese forces in New 
Guinea were constantly being reinforced and 
large base was being established at Rabaul 
f the Western Solomons. In addition, Japan 
was working feverishly to develop its gains 
in the East Indies and Malaya, and our sup- 
Iv lines through the Pacific to Australia and 
New Zealand were in imminent danger of 
being severed. Therefore, in order to consoli- 
date our preliminary gains in the Southwest 
pacific, to relieve some of the pressure on New 
Guinea and consequently on Australia, and 
to establish the first stepping-stone on the 
long march back to the Philippines, it was de- 
cided to mount an amphibious assault on 

had been instructed in first aid and immunized 
against smallpox, yellow fever, typhoid fever, 
and tetanus. 

Prior to the landings in the Solomons, plans 
were completed for the medical care of the 
thousands of officers and men by the organi- 
zation of the Medical Department into: (a) 
Battalion aid station units, composed of 2 
medical officers and 20 hospital corpsmen, of 
whom 3 were detailed as company aid men, the 
remainder being assigned with the medical of- 
ficers to the battalion aid station; (b) medical 
companies, consisting of 6 medical officers and 
80 hospital corpsmen and divided into 3 sec- 
tions : (1) collecting and sorting, (2) hospital, 
and (3) evacuation. Each medical company 

Figure 71. — Sickbay on Guadalcanal. 

Guadalcanal, a little-known island in the East- 
ern Solomons. 


The first echelon of the First Marine Divi- 
sion reached New Zealand on 14 June 1942, 
and on 7 August 11,000 men, a few units of 
fire, and a mountain of supplies were landed 
at Lunga Point, Guadalcanal. 

In preparation for combat duty, the per- 
sonnel of the First Marine Division had been 
carefully screened, and appropriate dispo- 
sition made of men not physically fit. All hands 

was capable of establishing a 72-bed hospital 
in the field (fig. 71) . 

The company aid men landed with and 
closely followed the initial assault wave, main- 
taining a position about 200 yards behind the 
front lines. They administered plasma and 
morphine, recorded on tags which were at- 
tached to the patient all treatment given, and 
applied necessary dressings and splints, 
thereby forming the first link in the elaborate 
chain of care established by the Medical De- 
partment (fig. 72), A few waves later, the 
battalion aid equipment and personnel were 
landed. On their arrival, stretcher parties (fig. 



73), formed largely from rear echelon troops, 
were dispatched to brin^ the wounded back 
to the battalion aid station, where additional 
lifesaving resuscitative measures could be in- 

and semiambulatory wounded. These went in 
land to battalion aid, and evacuated casualties 
to the beach, where they could be loaded aboard 
boats (figs. 75, 76), and carried to transpor 


Figure 72,— First aid for wounded marines at a frontline battle dressing station in 

the Solomons. 

Figure 73. — Collecting the wounded. 

stituted. Set up at a distance of about 600 
yards behind the line, these stations were con- 
stantly being moved forward as the assault 
progressed inland. 

Soon the collecting party, the advance unit 
of the medical company, landed with ambu- 
lance jeeps (fig. 74) fitted to carry stretchers 

anchored offshore. Because field hospitals early 
in the Guadalcanal campaign were targets for 
almost daily aerial bombing and/or artillery 
fire it became necessary to evacuate patients^ 
a distance of some hundreds of miles befo 
operations and other definitive measures coul 
be carried out. 



Figure 74. — Continuing first aid during transportation by jeep. 

Figure 75. — Carrying wounded aboard a landing boat for further transportation to an 

APA or hospital ship. 



Figure 76. — Transfusion of wounded immediately upon arrival aboard a landing 


Figure 77. — Litter carry of wounded on Guadalcanal. 



^vacmiion and transportation of casualties 

The usual method of evacuation of patients 
^as by hand-carried stretchers (fig. 77) along 
the shortest trail to the rear. Men v^ere then 
laced in the first available transportation — 
a jeep, an ammunition truck, or other vehicle 
_and taken back a distance of from 500 to 
1 000 yards to be transferred to waiting am- 
bulances, or else taken directly to a field hos- 

Early in the operation it was found that a 
litter squad of four men was inadequate to 
carry a casualty by stretcher over the type of 
terrain encountered, particularly in the heat 
of the day. This necessitated the employment 
of collecting section personnel as litter bearers 
from the front lines back to the first available 
transportation. To reduce the distance of hand 
carry, jeeps were sent to forward areas. Their 
small surface, low center of gravity, and abil- 
ity to travel in difficult terrain made them es- 
pecially valuable for evacuation, for with only 
slight alterations, the standard jeep could pro- 
vide transportation for three or four stretcher 
patients and one ambulatory patient. The 
medical department did not, at that time, have 
control over these vehicles and frequently the 

lack of transportation made long carries by 
hand necessary. 

Early in the campaign, lack of communica- 
tion facilities and centralized control delayed 
the evacuation of patients from the beaches. 
Conti'ol boats had been provided for, but no 
communication existed between them and the 
beach medical section. Further, although ar- 
rangements had been made to station a medi- 
cal otticer in the control boat to direct medical 
supplies and the flow of casualties to the ships, 
this plan was for some reason abandoned. Per- 
haps one of the most unsatisfactory features 
of the early evacuations by sea was the lack 
of effective coordination of the evacuating 
ships. Great inequities occurred in apportion- 
ing casualties among the ships, resulting in the 
overcrowding of the medical facilities of some 
vessels while other ships were only partially 
used. Many ships failed to fly the Mike flag to 
indicate that they could take casualties. Some 
boats carrying wounded made unnecessary 
stops en route for other purposes, and fre- 
quently coxswains would automatically head 
for the nearest ship to unload their patients as 
quickly as possible. 

With the establishment of the policy of 

Figure 78. — Air transportaticn of the wounded. 



evacuating from the island any patient who 
would not be fit for duty within 10 days to 2 
weeks, evacuation by air as well as by sea 
was inaugurated. Although a few casualties 
had been flown out earlier in combat aircraft, 
the first transport plane, accommodating 18 
stretcher cases or 36 ambulatory patients, ar- 
rived on 3 September 1942. By 18 September 
1942, 147 patients had left Guadalcanal by this 

As the war progressed and lines of com- 
munication became longer, air evacuation be- 
came of great importance, and both the Army 

ate flight at high altitudes. Air evacuation was 
a tremendous boost to the morale of all per* 
sonnel (figs. 78, 79) . 

During October and November 1942, more 
patients (2,879) were evacuated by air than 
by sea. Occasionally the transfer of patients 
from hospital to plane was even made while 
the field was under artillery fire. 


Sanitation on Guadalcanal was a tremen- 
dous problem. The enemy, surprised by the 
attack, had left a great deal of equipment as 
well as refuse. This could not be burned be- 

Figure 79. — Evacuation of casualties by air. 

and Navy increased their facilities for air 

transportation of patients. Further, nurses 
and corpsmen were specially trained for this 
duty and medical officers were assigned to 
screen those patients selected for transportation 
by air, with a view to assigning priority to those 
requiring specialized treatment in the fields of 
neurosurgery, ophthalmology, or plastic sur- 
gery, and to excluding patients with abdominal 
and chest wounds, who generally did not toler- 

cause of the danger of inviting aerial attack. 

Further, all enemy latrines w^ere unfit for use 
and had to be destroyed and new fly-proof 
facilities constructed. 

During the first few weeks, epidemic gas- 
troenteritis occurred. Later, catarrhal fever, 
dengue, and malaria w^ere the major medical 
problems. Fungus infection of the foot, groin, 
and intergluteal fold proved to be of minor 
importance only. 




Malaria did not appear until about 2 weeks 
^fter the landing. Suppressive treatment with 
atabrine was begun on 10 September 1942. Al- 
though instructions for its proper use were 
put out as a division order, it was impossible 
to g^^ complete cooperation in the distribution 
and ingestion of this drug even under bivouac 
conditions. Lack of supervision by the respon- 
sible line officers became apparent when hun- 
dreds of tablets of atabrine were picked up 
from the ground by messmen after they had 
been distributed to personnel. Thus, medical 
personnel were obliged, in most instances, to 
stand at mess lines not only to dispense the 
medication but also to look into the mouths of 
recipients to see that it was swallowed. Quinine 
was used as a suppressive dru^ only in those 
by whom atabrine was not tolerated. 

The lack of mosquito nets during the early 
phases was a factor in the high incidence of 
malaria. Although each man had both head and 
bed nets on embarking, most men lost or dis- 
carded their nets during the landing operation. 
Further, line personnel had little regard for 
the practical value of antimosquito equipment 
and believed that this equipment was more of 
a hindrance than a help. Their philosophy was 
that a man operating in the jungle, through 
steaming heat and pelting rain, far from any 
base of supplies and obliged to carry his every 
need on his back, had neither the time nor the 
strength to bother about mosquito bars, head 
nets, and gloves. His attention and energy 
were directed to the more immediate and ur- 
gent matters of killing the enemy and avoid- 
ing being killed. It was not appreciated by the 
line that a man infected with malaria w^as a 
casualty as surely as though he had been 
wounded by enemy action. 

It was well known that the natives of the 
Solomons were reservoirs of malarial infec- 
tion, and cognizant medical officers strongly 
opposed the introduction of native labor into 
the combat area of Guadalcanal. The com- 
manding general recognized the soundness of 
this advice, but the gravity of the tactical 
situation required all available troops on the 
firing line and therefore natives were employed 

to unload food, ammunition, and gasoline from 

the ships. 

The combination of an infected native popu- 
lation and a suitable mosquito vector spelled 

infection for the troops. Later Guadalcanal l)e- 
came the staging area for troops moving to 
the front in other campaigns, and the men 
carried malaria to other combat zones, where 
there were no natives. In the 20 weeks fol- 
lowing the arrival of the Second Marine Divi- 
sion on New Zealand from Guadalcanal, 9,215 
men (63.8 percent of the entire division) had 

The First Marine Division and supporting 
troops landed at the beginning of the cam- 
paign during the dry season. Malaria did not 
appear until some weeks later, but with rapid 
progression it threatened to become a critical 
factor in the success of the operation. The use 
of atabrine saved the military situation on 

In table 20, the number of admissions to the 
sick list in the First Marine Division for ma- 
laria is compared with those for other diseases. 

Table 20. — Xnmber of First Marine Division patients 
hospitalized for malaria as compared with other 
diseases— Guada Icanal 

Month 1942 


Other diseases 






The number of men who were infected with 
malaria on Guadalcanal may never be de- 
termined, but it is safe to assume that almost 
every man who served on the island during 
the period of 7 August 1942 to 9 February 
1943 fell victim to the disease. 


For the first 5 weeks after landing, water was 
obtained from the Lunga River and chlori- 
nated by hand by Medical Department per- 
sonnel. On 12 August a portable filtration and 
chlorination plant was set up on the west bank 
of the Lunga, providing 12,000 gallons daily. 
As the number of personnel increased and 



more water was needed to assure an adequate 
supply for all hands, the original chlorination 
unit was replaced by a mobile unit with a daily 
capacity of 30,000 gallons. Six portable units, 
each capable of chlorinating 12,000 gallons a 
day, were set up at different points about the 
island. Headquarters, Second Marines, also set 
up a water distilling plant on Tulagi. 


The food supply on Guadalcanal, inadequate 
at first, gradually improved as the operations 
proceeded, and enemy supplies captured in the 
first days added significantly to our limited 
stores. Food that was actually spoiled was sur- 
veyed but hunger often tempered the judg- 
ment of medical officers. As supplies arrived, 
the diet became adequate. Lack of equipment 
for the proper preparation of food was over- 
come by field and mess cooks, who show^ed 
great ingenuity in repairing and utilizing cap- 
tured equipment. Had the enemy taken the 
time to destroy his ration dumps and equip- 
ment, the outcome of this operation might have 
been tragic. 

Medical supplies 

On landing, the battalion and regimental 
medical sections were instructed to carry only 
combat medical supplies and equipment. In 
some instances individual groups disregarded 
this order and overloaded their medical per- 
sonnel with other equipment. This disregard 
of a carefully planned operation order often 
proved to be a serious handicap and con- 
tributed to the loss of valuable medical sup- 

The sinking of the Elliott by falling enemy 
aircraft resulted in the loss of practically all 
the medical supplies and equipment for E Com- 
pany, First Medical BattaHon. Division of sup- 
plies had been so well executed, however, that 
no shortage resulted. By sharing available sup- 
plies and using those captured from the enemy, 
it was possible to reoutfit this company and 
enable it to function as a field hospital within 
48 hours after landing. 

Practically all medical supplies destined for 
Tulagi, with the exception of the units carried 
by personnel, were lost. Under the supervision 
of tiie senior medical officer, the supplies re- 

maining were pooled and added to those cap. 
tured from the enemy, so that there was hq 
shortage of any essential material during the 
first week or 10 days. After this, it was pog, 
sible to obtain re-supply from the division 
depots on Guadalcanal. When the naval forces 
withdrew on the night of 9 August, the physi, 
cal occupation of Tulagi and Gavutu had been 
completed and a field hospital was in operav 

With the exception of a few items, medical 
supplies on Guadalcanal were adequate 
throughout the campaign. Deficiencies were 
rapidly corrected by air transport from the 
base depot at Noumea, New Caledonia. After 
the landing, this depot furnished all supplies 
except antimalarial drugs which remained un- 
der the control of Malaria Control Unit, South 
Paciftc. The arrival of the Seventh Marines, 
reinforced, on 19 September, gave the First 
Division an additional regiment of troops and 
/a completely equipped medical company. In 
spite of their reception by enemy gunfire and 
repeated air bombardments on their first night 
ashore, the medical company was operating 
a tent hospital just west of the Lunga River 
within 48 hours after arrival. 

By 10 December 1942 there were more than 
45,000 military personnel on Guadalcanal. The 
medical supply officer of the First Division 
obtained and distributed medical supplies to 
this entire group, and the First Division medi- 
cal section was able to fill requisitions despite 
the needs of many of the new units that had 
arrived with only a few days* supply. The 
Fourth Replacement Battalion was landed 
without any reserve supplies and the Eighth 
Regiment arrived with field units only. The 
Army was supplied from the First Marine 
Division reserves for the first 4 weeks of their 
action. Navy construction and aviation units 
had their own medical sections and the divi- 
sion medical supply officer was required to 
issue only supplementary supplies to them. 


The First Marine Raider Regiment landed 
on 5 July 1943, about 500 yards up the Punda- 

kona River on a sandy beach lined with man- 
groves. The battalion medical section, consist- 



inS ^ medical officers and 32 hospital corps- 
jnen, bivouacked with the troops until daylight 
in a drenching rain. At 0600, after discarding 
bed rolls and gas masks, the Northern Land- 
ing Group commenced the march to Dragrons 
peninsula. The movement from the Pundakona 
River to the Giza-giza River was made over 
three parallel trails previously cut by natives, 
^ith the First Raider Battalion in the lead. The 
^ray was obstructed by huge fallen logs, 
branches of trees, roots, and vines, and led 
through swamps and mud, and up and down 
steep coral hills. 

On reaching the Giza-giza River after 10 
hours and approximately 8 miles of jungle, the 
men, exhausted and thoroughly soaked by a 
heavy rain, slept in their ponchos. Another 
river crossing was completed by nightfall of 
the following day and another night was spent 
in a swamp with no protection from the ele- 
ments. At 0800, 7 July 1943, led by native 
guides, the battalion moved out through man- 
grove swamps, over fallen trees, banyan roots, 
and coral out-croppings. Troops became so ex- 
hausted that they threw away all unnecessary 
gear and a portion of their food consisting of 
K and D rations. No plasma was carried and 
the only medical supplies available were those 
carried in the hospital corpsmen's pouches and 
in individual first-aid kits. 

At 0700, 10 July, the battalion closed in on 
Enogai where intense fighting ensued. At the 
time battle was joined, the men had had no 
food and only 1 canteen of w^ater in 30 hours. 
The observation was made that ambulatory 
wounded w^ould immediately become litter pa- 
tients when given morphine, and it was appar- 
ent that this drug must be withheld from all 
except those having extensive wounds and 
extreme pain. 

Rushing between lines to administer first 
aid to a badly w^ounded marine during the ac- 
tion at Bairoko, PhM2/c Thaddeus Parker w^as 
killed instantly by a burst of enemy fire. His 
brave act, a source of inspiration to his fellow 
corpsmen and to the men of his company, 
served, however, to point out the importance 
of training troops to crawl back from the lines 
when wounded. On many occasions, men only 
slightly wounded called for help, and when 
their buddies or corpsmen went to their aid. 

they too were shot and injured or killed. 
Troops and corpsmen were cautioned not to go 
out in front of the line to get the wounded 
unless the lines were stationary or a with- 
draw^al ^vas being made or contemplated. If 
troops were advancing, the w^ounded would be 
behind the lines in a relatively short time. Had 
such a plan been faithfully carried out, fewer 
casualties w^ould have been sustained. 

The "Battle of Viru" began for the medical 
department of the Fourth Marine Raider Bat- 
talion on the morning they landed at Segi 
Point. It had been impossible, because of the 
lack of space on the APD, to take more medical 
supplies than could be packed in six ''unit 5's.'' 

Each corpsman carried a complete "unit 3,'' 
and each man in the battalion was given a 
supply of atabrine, halazone, salt tablets, 
aspirin, band-aids, and a morphine syrette, all 
of which were packed in a metal Carlisle Kit 
container. Once on the march to Viru, all sup- 
plies were cut off except for those contained in 
each "unit 3" and in the individual kits. 

It was imperative that Viru Harbor be taken 
in order that water could be obtained, sup- 
plies landed, and the wounded evacuated, so 
the last stream was crossed in the late after- 
noon and plans were laid for the battle which 
was to take place the following morn- 
ing. The rapidity of our advance precluded the 
development of front lines as such, and snipers 
and machine guns often operated in the rear 
of our troops. As a consequence, first-aid work 
was difficult, and the rapid movement of the 
fighting made the establishment of an aid sta- 
tion impracticable. About dark, preparations 
for moving the wounded on the trail to Viru 
were started. An aid station was established 
in a native hut at Tetamere Village and the 
w^ork of renewing bandages, cleansing 
wounds, and administering plasma began. 

At Vanguna, "unit 5's" were landed on the 
beach and later brought in after the village 
had been secured. An aid station, established 
in a Japanese mess hall, became the target of 
Japanese mortar and small arms fire. Water 
was not a problem here because the village was 
situated on a river bank. 

From the experiences in these two opera- 
tions the following observations were made : 



1. Evacuation of the seriously wounded over 
jungle trails frequently resulted in their death. 

2. Over such trails at least 6 men per litter 
were required, and they had to be rested for 
15 minutes every 300 to 500 yards. 

3. Plasma was required for every litter pa- 
tient if shock was to be effectively prevented. 

4. Morphine made a litter patient out of one 

who was ambulatory, and therefore had to be 
used with extreme caution in those with rela- 
tively minor wounds. 

5. Dressings were not to be changed unless 
there w\is evidence of bleeding c/r infection. 

6. First Aid Units Nos. 1 and 3 were found 
to be impractical. After removal of several bat- 
tle dressings, the unit became a jumble. At 
times it was necessary to empty the contents 
on the ground in order to find a single item. 
A number of the corpsmen used the I'egular 
Navy battle pouches; these had a large flap 
which permitted rapid location of every item. 
They were also easier to carry because of the 
wide shoulder strap. 

7. Special lightweight stretchers were pro- 
vided but these were discarded because of their 
weight when wet. Stretchers made of light- 
weight waterproof material, with slots in the 
sides for poles, and weighing not more than 
2 or 3 pounds when wet, were essential for 
long treks through the jungle. 

8. Higgins boats equipped with medical sup- 
plies and fitted with brackets for holding 
stretchers would have been of great value in 
moving the wounded down rivers to the coast 
and out to ships. Often the rivers were the 
only means of transportation in the dense 

Medical personnel were often handicapped 

in the treatment of casualties. No hospital 
facilities were available in the New Georgia 
area until 28 July 1943, 4 weeks after the 
campaign started, at which time a field hos- 
pital was hurriedly established on Kokorana 
Island. Previously, the nearest hospital was on 
Guadalcanal, 200 miles away and 20 hours by 
boat. No air evacuation was available except 
by emergency Dumbo (PBY) until August 
1943. By that time, however, 90 percent of the 
casualties had occurred. 

First-aid measures carried out in the h^!^ 
talion aid stations included debridement, fo^ 
eign body removal, and bandaging. SulfonJ 
mides, both locally and by mouth, were usej 
extensively. In the forward areas plaster of 
paris splints were used a great deal and pa, 
tients so treated reached the rear area in good 

Medical supplies for most of the New Geor. 
gia operation were provided by the Army. The 
original plan called for supplies for a total o{ 
60 days; a 30 days' supply was to be carried 
by units in the field and another 30 days' sup. 
piy was to be forwarded as soon as practi. 
cable. Sulfonamides, dried blood plasma, in. 
travenous saline and dextrose solutions, bat- 
tie dressings, morphine syrettes, first-aid pact 
ets, plaster, tetanus-toxoid, and other iteim 
that were expended rapidly in combat were m 
be available in amounts appi'oximately 10 
times the normal allowances. Individual jun. 
gle medical kits were supplied on the basis 
of one per officer or enlisted medical man and 
one per four other enlisted men. A 60-day sup- 
ply of atabrine was kept on hand at all times. 
Most of the necessary supplies came from the 
medical supply depot at Guadalcanal. 

The Forty-third Division, which had sole 
responsibility for medical supplies for the en- 
tire operation from 30 June to 28 July, experi- 
enced great difficulty in carrying out its plans. 
Before moving to the combat area, the Divi- 
sion secured supplies far in excess of the need, 
the tendency being to take all they could get. 
Accordingly, only a small portion of the huge 
stores accumulated on the beach could be taken 
along, and in the confusion of embarking for 
combat many essential items were left behind. 
The result was that instead of 30 days' medi- 
cal supplies accompanying the units, it was 
estimated that only 10 days' supplies were 
brought along. Further, because containers 
were not clearly marked to show their contents, 
medical supplies on being unloaded were fre- 
quently hopelessly mingled with those in ra- 
tion, fuel, and ammunition dumps. In less than 
3 days after landing, additional medical sup- 
plies were urgently needed. 

Some medical units waited until their sup-' 
plies were exhausted, then radioed to Guadal- 



canal for air shipment. This same condition 
existed to a large extent throughout the cam- 
paign, and indicated a need for better medi- 
cal supply handling. 


Flies and mosquitoes were a serious prob- 
lem throughout the campaign. Further there 

^as a lack of screening, which in the tropics 
offered more protection to the health of per- 
sonnel than armor plate. Because of these fac- 
tors, combat units would often lose 25 to 50 
percent of their combat efficiency from disease. 

The Twenty-fifth Division showed a much 
more favorable malaria rate during the New 
Georgia campaign than it did at Guadalcanal 
during the noncombat phase. The commanding 
officer of that Division from the beginning had 
the advantage of the advice of a group of 
trained malaria control personnel regarding 
the pattern of the disease and methods of pre- 
vention. Equally important, the command con- 
sistently followed the recommendations made 
by the malaria control officer (fig. 80) . 

One of the most spectacular achievements 
of the Malaria Control Unit was their convinc- 
ing proof that infected native laborers were 

the major factor in epidemic malaria and that 
they were responsible for a far greater loss 
of man-hours among the troops because of 
malaria than could be gained by their presence 
as laborers. 

Infections and combat fatigue 

Fungus infections occurred in about 25 per- 
cent of the entire New Georgia Occupation 
Force. In some units, notably Construction 
Battalions, the nature of their work was such 

as to prevent good personal hygiene. In one 
construction battalion 10 to 15 percent of the 
command appeared daily at sick call for treat- 
ment of fungus infections of the skin, and foot 
infection was seen in approximately 30 per- 
cent. The issue of socks was inadequate, bath- 
ing and laundry facilities were insufhcient, and 
bathing at night was prohibited by malarial 
control directives. 

The most serious medical problem in the 
New Georgia operation was the relatively high 
incidence of combat fatigue, exhaustion states, 
and "war-weariness.'* During the period from 
30 June to 80 September, approximately 2,500 
men were admitted with the diagnosis of 
anxiety reaction. Aviation units, which were 

Figure 80. — Natives under supervision of Malaria Control Unit personnel oiling the 

pools on Munda, New Georgia. 



Figure 81. — Evacuation of casualties in an LST. 

not subjected to the severe living conditions 
found at the front line, and which were ro- 
tated after 2 months, suffered few casualties 
from combat fatigue. 


A total of 8,225 patients were evacuated 
during the New Georgia campaign by air and 
7,300 by sea. For the first 4 weeks of the oper- 
ation, each LST evacuating casualties to 
Guadalcanal had only one medical officer, al- 
though there were from 100 to 200 casualties 
aboard (fig. 81). 

Timing the arrival of evacuees at the beaches 
was a difficult problem. The LST's would ar- 
rive early each morning, unload during the 
day, and depart by 1800 the same day. The 
patients had to be rushed aboard immediately 
after the completion of unloading, whatever 
the state of the weather or enemy activity. 

Because of the limited number of hospital 
beds in the New Georgia area, patients were 
evacuated on the day they were injured. Al- 
though the actual sailing time of an LST to 
Guadalcanal was only about 20 hours, many 
casualties who had received but little first-aid 
treatment did not reach medical installations 
on Guadalcanal until from 72 to 84 hours after 

injury. This time factor and the limited medi- 
cal facilities aboard the LST's contributJ| 
materially to the incidence of gas gangrene and 
infection in the early days of the campaign.^ 
The percentage of patients with gas gangrene! 
was high: The First Corps Medical Battalion! 
had 24 patients with gas gangrene, six of whojjl 
died ; Naval Mobile Hospital No. 8 admittM 
20 patients with gas gangrene, of whom ofl 
died. ■ 


The assault against the Japanese on Bom 

gainville, the largest of the Solomon Islands,! 
was via Empress Augusta Bay, a low swampl 
area. The medical section of the naval landi™ 
party (1 medical officer and 8 hospital corps-| 
men) provided first aid (fig. 82) and madej 
provision for the evacuation of casualties (flal 
83). The First Marine Amphibious Corps as- 
signed 3 medical companies to set up three! 
400-bed hospital facilities (fig. 84). The firffl 
was set up within a few hours after landing, 
but the erection of the other two was delaye| 
for days because the medical personnel weri 
ordered to unload ships. Thus the medical de- 
tachments were hampered in making the most^ 
efficient use of personnel and materiel. I 



Figure 82. — First aid in a foxhole in the jungle at Empress Augusta Bay. 



Figure 84. — Bomb shelter below sickbay on Bougainville. 
Evacuation Filariasis '92 

The Solomons campaign was a joint Army comba^fatt^^^^^ 749 

and Navy operation, but on Bougainville the ^ a gue 

Navy Medical Department had the sole respon- — , , ^ . 

^ * . i Among men previously stationed in Samoa. 

sibility for the evacuation of all casualties 

from the Island. Under such centralized con- contrast to this, the morbidity rate among 

trol, evacuation of casualties was earned out ^^^^^^ Japanese on the Islands was ter- 

in a most creditable manner with a mmimum ^.^^^ ^g^^^^ ^.^^ ^^^^^^ 3 qqq ^^^^ j^-jj^^ 

of delay in transporting the sick and wounded ^^^.^^ ^^.^^^ because of illness, 

to hospital facilities. predominantly malaria, tetanus, beriberi, and 

Disease dysentery. 

^, . - ^ ^ ^3^„n.o^«.r;^^.. The low morbidity rate among American 

The mcidence of disease on Bougainville , , , ^ ^ . 4.4. -u 4. ui^ 

. ,1 , ^-P troops, on V about 1 percent, was attributable 

was amazingly low and was the cause of no ^^^^h^^y , . . i 

15 J ^ following sanitary control measures 

evacuations, although it was estimated that- 7^ ^ ° 

50 percent of the troops were seeded with ma- • 

laria. Mild diarrhea and dysentery were ex- 1. Administration of 100 mg. of atabrine 

perienced by the majority of the personnel to all troops. 

but the use of sulfonamides reduced the dura- 2. Lectures, pamphlets, and motion pictures 

tion and severity of the attacks. used in indoctrinating personnel in pre- 

The diseases most prevalent in the First measures. 

Marine Amphibious Corps were: 3. Use of pyrethrum spray and mosquito- 
proof hammocks. 

Malaria ^9^' 4. Effective action of Malaria Control Unit 

Dysentery 103 personnel. 

Figure 86. — ^Mobile Malaria Control Unit in action. 



New Hebrides 

A large number of men were evacuated from 
Espiritu Santo because of asthma and allied 
conditions caused by pollens and molds. Some 
of the fungi had a predilection for the stuffing 
of pillows and mattresses. 

A denguelike disease existed in epidemic 
form on the island. In some organizations it 
affected about 12 percent of the men. 

In addition to the swamps and stagnant 

pools, there were numerous piles of tin cans, 
garbage, coconut husks and fronds, and other 
waste material, which served as breeding 
places for flies and mosquitoes. As a result, ap. 
proximately 80,000 sick days occurred among 
Army and Navy personnel in 3 months, despite 
the efforts of the Sanitation and Malaria Con- 
trol Units (figs. 87 and 88). 

Figure 87. — Supply yard of Malaria Control Unit on Espiritu Santo. 

Figure 88. — Malaria control on Espiritu Santo. 



The natives were poorly nourished. Tubercu- 
losis, yaws, malaria, filariasis, and intestinal 
parasites were common, and leprosy was seen 
oecasionally. Physical examinations of a group 
of candidates for employment showed that 22 
percent had filariasis and 18.5 percent showed 
positive smears for malaria. The natives from 
a nearby island had a filariasis rate of 51.5 

On Espiritu Santo, naval medical officers or- 
ganized the Espiritu Santo Medical Society, 

which was addressed by medical officers as 
well as local civilian physicians. Among the 
interesting lectures was that of Doctor Astaire, 
a Fijian physician who had graduated from 
the Fiji Medical School. He stated that he had 
never seen a case of measles or tetanus among 
the natives and only a few of cholecystitis, ap- 
pendicitis, and leprosy. He believed that ma- 
laria, pneumonia, and mumps, of which there 
had been an epidemic two years previously, 
had been introduced by the white man. 


During the early phases of the assault on 

Saipan (June 1944), the scene of sand, blood, 
and wreckage was intensified by an atmos- 
phere of extreme confusion. Seabee, Marine, 
and naval shore party detachments had duK 
into foxholes over the entire area above the 
high watermark. Shelling of the beaches was 
continuous, and the nerves of both officers 
and men were strained to the breaking point. 
To add grimness to the environment, the dead, 
both Japanese and American, had l)een col- 
lected and laid out to await trucks for trans- 
portation to a burial ground. 

Into this melee, medical units were landed 
in LVT's and LCT^s (fig. 89). The first groups 
to establish medical order were the medical 
sections of the beach parties. Composed of 1 
medical oflScer and 8 hospital corpsmen from 
each troop carrier, they constituted the link 
between medical organizations afloat and 
ashore. Working in highly exposed positions 
for as long as 48 hours at a time without rest 
and subjected to the added hazard of strafing 
Japanese planes, they gave emergency medical 
treatment and set up casualty evacuation sta- 
tions in the sand. During the long hours when 
the invasion forces were confined to the 
beaches, battalion aid stations acted as for- 
ward emergency and evacuation centers on the 
beaches. From these stations the company aid 
Rien went out to administer first aid, expos- 
ing themselves to enemy fire in order to reach 
the wounded. Their bravery was reflected in 
the heavy casualties among Hospital Corps 
personnel. Their sacrifices were not in vain, 
however, for the most important factor in sav- 

ing of lives had been shown to be the early 
transfusion of plasma or whole blood (fig. 90) 
and the removal of wounded from the beaches 
to ships where lifesaving resuscitative meas- 
ures could be promptly instituted. In the 
Fourth Marine Division, 161 medical officers 
and hospital corpsmen became battle casualties 
because they were unable to utilize protection 
or seek cover from enemy fire. Casualties in 
personnel during the first 5 days of the opera- 
tion wei'e enormous. One shore party evacua- 
tion station treated and evacuated 1,009 cas- 
ualties during the period from D-Day to D~ 
Day plus 3 under the most difficult conditions. 
Jeep ambulances with their loads of wounded 
were often hit by artillery fire; the landing 
of ammunition and gasoline near casualty 
evacuation centers on beaches that were sub- 
jected to continuous shelling did not lessen 
the difficulties of rendering first aid. 

Medical supplies for this campaign were 
packaged in blocks, each of which contained 
a 30-day supply for 3,000 men. Items such as 
the Wangensteen suction apparatus and a suf- 
ficient number of intestinal clamps, airways, 
and oxygen apparatus were lacking. 

Shortages of litters, tetanus antitoxin, 
blankets, l)lackout tents, and penicillin de- 
veloped. Always in demand, litters were fre- 
quently not returned from ships, while break- 
age and loss in the burial of dead added to 
the shortage. Fifty more litters per troop 
transport, where landing force evacuation 
lines were long and casualties heavy, were 
recommended by the senior medical officer. 


Figure 89. — First-aid station being set up on the beach at Saipan. 

Figure 90. — Blood and plasma transfusions on the beach at Saipan. 


Figure 91.— Transporting the wounded in a rubber boat. 

The presence of coral reefs and the loss of 
small boats during the assault made evacua- 
tion of casualties difficult. Unfortunately, the 
most effective evacuation ship, the LCVP, could 
not be beached because of the coral reef, but 
the DUKW was useful in the evacuation of 
casualties over the reefs. Rubber boats were 
also utilized to transport the injured (fig. 91). 

As the battle for Saipan progressed, the 

lines of communication became longer and the 
need for vehicles increased. Not enough jeep 
ambulances had been provided — only one was 
available for each medical battalion. When 
casualties were heavy, other jeeps were req- 
uisitioned, but frequently the requested jeeps 
were lost on the way. 

Another important problem in evacuation 
during the early phase of the invasion was 

Figure 92. — Second Marine Division Hospital in a captured Jap radio station. 



that of segregation of slightly wounded pa- 
tients from the more seriously wounded. Sort- 
ing was extremely difficult on the beaches, 
where hundreds of wounded arrived at one 
time and mud vied with enemy fire to frus- 
trate attempts at first aid and casualty evacu- 

Field hospital facilities 

Hospital facilities at Saipan functioned very 
well despite the heavy admission rate, but a 
number of difficulties were noted in the field. 
No provision had been made for a movable 
liKhtproof shelter in which the wounded could 
receive adequate treatment on the beach dur- 
ing the night. The maintenance of a strict 
blackout was essential, and it was almost im- 

possible to diagnose a surgical lesion or treat 
a wounded man under the pale blue gleam of ^ 
flashlight. Each corps hospital, however, ha| 
portable operating rooms that were easily 
blacked out and were of immense value. One 
medical company took over a small field hos, 
pital captured at Charon Kanoa, which in the 
early days of the operation w^as the only f aci 
ity for surgery. 

The best hospital facilities were those of the 
Second Marine Division. A former Japanese 
radio building (fig. 92), constructed of steely 
and concrete and surrounded by 10-foot re.! 
vetments was rapidly cleared of rubble andl 
damaged machinery with the assistance of ^ 
company of Seabees, and a hospital of 1,000 
beds for the seriously wounded set up. Patients 

Figure [Kl. — Emergency surgery in a hospital on Saipan. 



^th minor wounds were housed in tents. Eight 
operating tables were manned by specialized 
surgical teams for orthopedic, chest, abdomi- 
nal, and head and eye injuries. Eleven other 
operating tables were available for use in treat- 

power resulted when others became panic- 
stricken at the realization that their leaders 
were no longer able to direct them. (6) 
The lack of proper orientation was probably a 
contributing factor. The fighting man wished 

Figure 94. — Modern diagnostic procedures on a battlefield on Saipan. 

ing shock, giving ti-ansfusions, and caring for 
minor injuries. A major factor in the excellent 
functioning of this hospital was the strong 
centralized organization of the medical battal- 
ion (figs. 93 and 94). 

Disease and combat fatigue 

Diseases and combat fatigue accounted for 
about one-third of the admissions. In the Fourth 
Marine Division, there were 409 patients ad- 
mitted for dengue fever, 680 for dysentery, 26 
for fungus infection, 414 for combat fatigue, 
and 169 for psychoneurosis. 

The high incidence of neuropsychiatric ill- 
ness appeared to be attributable to a number 
of factors, among which were: (a) Leaders of 
small units, on the whole, did not demonstrate 
the inherent qualities of leadership. Junior and 
noncommissioned officers were often the first 
to '^break,'' and a needless sacrifice of man- 

to know what was going on, what was expected 
of him, and what he could expect. He also had 
to have a definite objective. Without proper 
orientation he was prone to absorb wild rumors 
and loose talk, and was thus subjected to con- 
stant mental stress, (c) It was likely that a 
loss of physical fitness contributed to the high 
incidence of anxiety reactions. 

About 50 percent of those patients with a 
diagnosis of neurosis should have been diag- 
nosed as combat fatigue. Another 20 percent 
were borderline cases in which fatigue and ex- 
haustion contributed to the symptoms. Three 
or four days rest, a bath, and nourishing food 
resulted in complete recovery in from 75 to 80 
percent of these patients. 

Burial of the dead 

One of the great problems confronting the 
Medical Department was the speedy and ef- 



Figure 95. — U. S. Marines pay final tribute to their buddies in the Solomons. 

fective burial of the dead and the disposal of 
the decomposing bodies in block houses and 
bomb shelters. On Saipan thousands of United 
States and enemy dead lay on the beaches and 
the rugged inland terrain. Prior to the land- 
ing, careful plans were made for burial of the 
dead and details were trained and equipped 
for this work (figs. 95 and 96). Because of 
the intensity of battle, however, there was 
often a delay of several days before burial or 

disposal of the large numbers of enemy deq 
could be started and the amount of sodii 
arsenite and oil for spraying the remains w| 
frequently insufficient. Other factors that ii[ 
peded the burial parties were: (a) Absence 
identification tags with consequent delay 
identification; (b) shortage of litters on whi^ 
to carry the dead; and (c) lack of adequa 
communication facilities between bur3 
parties and the Division Burial Officer. 




puring the first week on Saipan, there were 
mple facilities in AH's and APA's for cas- 
ualty evacuation. On D-day-plus-11, however, 
the APA's were withdrawn and there were 
then insufficient personnel and hospital facili- 
ties for the stream of wounded, averaging 500 
per day. 

Air evacuation was begun on D-day-plus-9 

and 860 patients were evacuated, but because 
there were no flight surgeons to screen the 
patients and no medical attendants to accom- 
pany them, some died en route. At times, men 
wounded in combat who had been without food 
for days were evacuated without being fed. 
Further, on arrival at Eniwetok or Kwajalein, 
inadequate preparations had been made to care 
for these air evacuees. 

Iwo Jima 

Medical planning for the Iwo Jima cam- 
paign began in October 1944. In preparation 
for the operation, Medical Department repre- 
sentatives of the Navy, Marine Corps, and am- 
phibious units that were to participate, held 
numerous conferences to discuss the tactical 
and logistic problems. The nature of the ter- 
rain on Iwo Jima was such that there could 
be no tactical surprise; the Marines had to 
land on the southeastern beaches, and make a 
frontal assault. Under the circumstances, 
heavy casualties were anticipated. For pur- 
poses of computing anticipated casualties, it 
was assumed that the period of active combat, 
from the beachhead landings to seizure of the 
objective, would be 14 days ; that 5 percent of 
the entire attacking force would become cas- 
ualties on the first and second days, 3 percent 
on the third and fourth days, and 1.5 percent 
on each of the remaining 10 days. 

Casualty estimates, arrangements for hos- 
pital beds, and assignment of hospital and 
other ships for the evacuation of the injured 
from combat area were responsibilities of the 
Medical Logistic Section of CinC Pac POA. 

On the basis of the Army Field Medical 
Manual, as modified by recent experience and 
the most reliable evaluation of enemy potential 
to be gained by aerial observation and combined 
intelligence, it was estimated that our losses 
would approximate 20 percent of the forces 
engaged. Of these 25 percent would be killed 
in action, 25 percent would be returned to duty 
locally, and 50 percent would be evacuated. 
Taking into consideration civilian casualties 
and enemy wounded to whom we were likely 
to be required to furnish medical care, defi- 

nite plans were formulated with regard to 
evacuation policy, the number of beds and 
ships required for hospitalization and evacua- 
tion, and the volume of medical supplies to be 

Each medical company and corps medical 
battalion had equipment for a 144-bed hos- 
pital, twice the numl)er allotted prior to the 
Marianas campaign, making available approxi- 
mately 3,592 beds. It was also planned by the 
Eighth Field Depot, scheduled to arrive about 
D-day-plus-10, to add to their stock a suffi- 
cient amount of cots, tents, blankets, and mess 
gear for another 1,500 beds. 

The chain of evacuation of casualties in- 
cluded 4 LST(H)'s or evacuation control 
LST's, specially equipped with medical person- 
nel and supplies and designated to make 
preliminary "screening" examinations of cas- 
ualties and distribute them equally among the 
transports and hospital ships. One LST(H) 
was available for each of the invasion beaches, 
making two for each Marine division. All ships, 
LVT or DUKW, that evacuated wounded from 
beaches were to proceed to their respective 
evacuation control LST(H). Those casualties 
unable to endure the trip to a transport or 
hospital ship were to be transferred immedi- 
ately to an LST(H) for treatment, while less 
seriously wounded patients were unloaded 
onto a barge alongside the LST(H) and then 
transferred to LCVP's for further transfer to 
transport or hospital ship. 

Aboard each LST(H) were 4 surgeons and 
27 corpsmen, increased on arrival at the ob- 
jective by the transfer of one beach party 
medical section (1 medical officer and 8 corps- 



men) from an APA, giving each LST(H) 5 
surgeons and 35 corpsmen. At all times these 
beach party medical sections were on call by 
the Transport Squadron Commander. 

Two hospital ships and one APH were des- 
ignated to evacuate patients to Saipan, where 
1,500 beds were available, and to Guam, where 
there were 3,500 beds. Air evacuation of cas- 
ualties to the Marianas was to begin as soon 
as field facilities would permit. Experience 
gained in the Marianas campaign had empha- 
sized the necessity of having the casualties 
screened by a qualified flight surgeon to in- 
sure proper selection of patients for evacua- 
tion by air. Medical personnel and adequate 
medical supplies and equipment were to be 
aboard each plane. 


Because there was a possibility of epidemic 
typhus, scrub typhus, cholera, and plague at 
the objective, all personnel were inoculated 
aga^inst these diseases, in addition to the usual 
immunizations. The clothing of personnel of 
the landing force was impregnated with 
dimethylphthalate and DDT powder. As a 
means of controlling flies, which had been such 
a nuisance and a hazard to health in previous 
operations, the area was sprayed with DDT by 
carrier-borne aircraft and later, by land-based 
planes. A medical oflScer familiar with the pro- 

cedure was detailed aboard a carrier as tech. 
nical advisor, and the malaria and epidemic 
control team of the Fourth Marine Division 
was designated to furnish the technical ground 


The medical supply plan for the operation 
included an initial 30-day allowance carried 
with the assault forces, plus medical and sani- 
tary suppKes for 1,500 civilians, as well as the 
provision for "block" shipments which were 
to arrive at regular intervals. Approximately 
50 percent of the supplies of the assault forces 
and all of the "block" shipments were to be 
palletized (packaged) and waterproofed. Plans 
also provided for adequate emergency resup. 
ply that could be sent by air if necessary. 

Experience gained in previous operations 
had shown the great need for a blood bank. 
With the establishment of Whole Blood Dis- 
tribution Center No. 1 at Guam (fig. 97), it 
became feasible for the first time to set up a 
blood center at the target area and plans were 
made accordingly. Up to this time whole blood 
had been obtained from hospital corpsmen, 
Marines, and occasionally from patients. 
LST(H) 929 was designated to carry the whole 
blood bank for distribution to the forces both 
afloat and ashore. When the military situation 
permitted, the blood bank was to be landed and 

0«ld«iKl» CalllorniB vl> NATS 

Figure 97. — One of the most important phases of military medicine was the rapid distribution of whole 
blood to every fighting front. 



established ashore. All ships were ordered to 
i-eceive whole blood in the quantities shown: 
gach APA, 16 flasks ; LSV Ozark, 500 flasks ; 
TgT(H) 929, 1,100 flasks (whole blood bank) ; 
each AH, 812 flasks; and LST(H)'s 9S0, 921, 
and lOSSy 16 flasks. 
Additional whole blood was to be furnished 
incoming AH's, or was to be flown in from 
Guam when air facilities were organized. 


Prior to the operation, medical battalions 
were instructed to carry an additional 1,500 

blankets, 5 million units of gas gangrene anti- 
toxin, and 50 million units of penicillin. An 
inspection was made of the jungle kits and 
identification tags of each man in the division 
of all Medical Department supplies and equip- 
ment. All shortages were corrected. Medical 
personnel were given additional instructions 
in first aid, in the keeping of medical records, 
in the automatic exchange of litters, and in 
the handling of casualties in and out of boats. 
At the close of the training period, a practice 
landing was made to give the medical person- 

nel an idea of what to expect when landing 
on the target. 

A serious problem was the fact that sur- 
geons who were to be called upon to perform 
operations during the battle had had little op- 
portunity to perform any surgery during the 
6-month period prior to the campaign. To cor- 
rect this situation, a division hospital was 
operated during the preparatory period. 

The medical personnel were embarked with 
the regimental combat team, as designated by 
the unit medical officers. When practicable, 
hospital sections of the medical companies 
were embarked on ships with the largest bed 
capacity in order to facilitate the care of cas- 
ualties during the initial stages of the battle. 
Basic vehicles were combat-loaded with essen- 
tial items of equipment and supplies to sup- 
plement those designated as *'hand carry." 
wSeabags w^ere packed with battle dressingT=>, 
plasma, serum albumin, and other items essen- 
tial during the early stages of the assault. 
These were to be carried ashore by the assault 
medical company. Two and one-half ton 6 by 
6 trucks, for the first time part of the medical 

Figure 08. — Landing medical supplies on Blue Beach at Iwo Jima. 



battalion, were combat-loaded with equipment 
and supplies necessary to establish surgical 
units ashore. 
Landivq of medical units 

The Fourth and Fifth Marine Divisions, 
supported by the Fifth Fleet, began landing on 
the southeast shore of Iwo Jima at 0900, 19 
February 1945 (fig. 98). The Third Marine Di- 
vision, which had been held in reserve, was 
landed on D-day-plus-2. Company aid men were 
debarked with platoons, battalion aid station 
personnel with battalion command iKXsts, and 

The grueling experience of all battalion 
corpsmen and medical officers was typified by 
the following account: 

"Landing witli the troops, immediately following the, 
assault group, the chief pharmacist's mate was sho 
in the jaw as he stepped out of the landing boat. Tlj 
medical party, carrying seabags filled with medic- 
supplies, pushed inland some 75 yards and picked a 
spot for their station in an antitank ditch. They left 
some of the bags on the beach on that first trip, and 
when they returned to get them, many of the bags had 
already been ripped by shell bursts. Boxes of valuables 
plasma were smas^iied, but the worst blow came wheM 

Figure 99, — Administering blood plasma in a foxhole on the invasion beach at 

Iwo Jima. 

regimental aid station personnel with the regi- 
mental command posts. Shore party medical 
personnel in support of battalion landing teams 
were debarked prior to H-hour. Four medical 
shore party evacuation teams were landed 
between H-plus-30 and H-plus-120 minutes 
(0930 to 1100). Other division and corps medi- 
cal units were landed as rapidly as the military 
situation would permit. In'^^the early phase of 
the assault, aid-station personnel were sepa- 
rated into small groups and worked in shell 
craters or foxholes in the sand (fig. 99). 

the boat carrying all the litters was sunk on the 

way in. 

Wounded men were lying all around. It was impos- 
sible to stand erect on the beach, and the corpsmen 
crawled from casualty to casualty to bandage wounds 
and administer morphine and plasma (fig. 100). 
Within an hour after the aid station had been set 
up, a shell exploded on one side and fragments in- 
jured several of the men. The medical officer, realiz- 
ing that the revetment, thou^arh appearing- to offer 
good protection for an aid station, was a logical tar- 
get for Jap guns, ordered the men to pack up equip- 
ment, and move to a large bomb crater, where the 
medical personnel continued their work." 



Figure 100. — First aid on the invasion beach at Iwo Jima. 

In the fury of the battle there were many 
dramatic instances of rescue and treatment. A 
Marine who had been blinded and had both 
hands blown off, was groping his way toward 
the beach when a corpsman saw him and ran 
a gauntlet of fire to get him to safety. A corps- 
man in battle for the first time sewed up four 
chest wounds under fire and undoubtedly 
helped save the lives of the four injured men. 
A corpsman crawled to the aid of Captain 
Dwayne E. ''Bobo" Mears, who had been shot 
through the neck and was in shock from the 
loss of blood. He buried the low^er part of the 
Captain's body in the sand so that he would 
offer a smaller target for the Jap riflemen. 
It helped, but the captain died later aboard 
a hospital ship. 

Care and evaciiatiofi of casualties 

The care and evacuation of casualties during 
the Iwo Jima campaign was handled better 
than in any previous operation in the Central 
Pacific area. Notwithstanding the extreme bit- 
terness of the combat and a casualty rate in 
excess of 1,000 per day during the first 21 
days, evacuation functioned as a well-inte- 
grated and coordinated operation and the 
wounded received the best medical care com- 
mensurate with the military situation. By 



D-day-plus-33, a total of 17,677 casualties 
had been treated and evacuated. 

(^:isMalties were assisted in walking down 
from the firing hne (fig. 101), or were brought 
by hand-carry, jeep, ambulance (fig. 102), 
half-track, or weapon carrier. Because of the 
rugged terrain, hand-carry frequently had to 
be employed to move the wounded to the beach- 
head over the rough lava cliffs and sharp- 
edged blocks of stone and lava. While the 
beachhead was being secured, casualties were 
evacuated from battalion aid stations directly 
to the beach, where they were turned over to 
shore and beach party installations set up in 
shell holes or in small pits dug in the volcanic 
sand (fig. 108). Plasma and other first-aid 
measures were administered while bullets sang 
overhead and mortar shells burst in close prox- 

After the troops were well established on 
the beach, the distance from the battalion and 
regimental aid stations to the beach was so 

short that casualties were evacuated by sea 
(fig. 104). When division and corps hospital 
installations were established on D-day^ 
plus-9, evacuation was from battalion and 
regimental aid stations to the division hospital 
nnd from there to the beach or to the corps 
hospitals. Casualties were so high and space to 
set up hospitals was so limited that many of 
the hospital sections of the medical companies 
supporting the regimental combat teams that 
were landed early, remained on the beach to 
assist in the shore party evacuation stations 
until division and corps hospital installations 
were functioning. Initial treatment of casual- 
ties in regimental and battalion aid station) 
was so efficient {fi^?>. 105 and 106) that many 
casualties who would otherwise have diei 
reached the shore evacuation stations am 
corps hospitals in excellent condition. Serum 
albumin was exceptionally well suited for use 
by frontline medical units, because of the easi 
of administration, small bulk, and the excelleni 

Figure 102. — A wounded marine brought to the beach by jeep ambulance from the 
fighting front on Iwo Jima. Fifteen minutes later he was on his way to a hospital 
ship off the shore of the island. 



Figure 103. — ^Marine stretcher bearers carrying the wounded into a foxhole for first 


Figure 104. — Corpsmen bringing the wounded from the front lines to evacuation ships 

on the beach. 

clinical response. Its therapeutic effect was 

equal to that of plasma. 

Casualties in Hospital Corps personnel were 
very high. In moving about to care for the 
wounded, corpsmen were subject to intense 
enemy fire and frequently were shot down 
alongside their patients. Although each divi- 
sion was assigned approximately 5 percent 
more corpsmen than were provided for by 
Tables of Organization, this was often insuf- 
ficient. In the Fourth Marine Division the cas- 
ualty rate among corpsmen was 38 percent. 

Often, because of urgent need for replace- 
ments, personnel were obtained from medical 
companies. In one division this policy was car- 
ried to such an extreme that on D-day-plus-8 
one medical company had been reduced to a 
point where it was almost inoperative. This 
practice was contrary to established doctrine 
and in some instances left insufficient person- 
nel in other areas to render proper care to the 

Close liaison betw^een the attack force sur- 
geon and the landing force surgeon resulted in 

258015—53 8 



a well-coordinated chain of evacuation from 
shore to ship. On D-day, 19 February 1945, 
30 APA's, 12 AKA's, LSV Ozark, and 4 
LST(H)'s were available for the evacuation 
of casualties. The general plan for sea evacua- 
tion provided that an LSTOH) be stationed 
500 to 2,000 yards off each of the 4 beaches 
and that all casualties be evacuated to one of 
these ships. 

During the early phase of the assault, prior 
to the establishment of^ fully functioning shore 
evacuation stations, the primary duty of 
LST(H) 's, was to render emergency treatment 
and receive casualties at night. In previous 
operations, casualties had been known to ride 
all night in open boats before finding a ship 
to receive them. After shore evacuation sta- 
tions were established, the main purpose of the 
LST(JI) was to effect an equitable distribu- 
tion of casualties to APA's and AH's. 

The work performed by LST(H)'s can be 

appreciated by the following: LST(H) 9S1 
was stationed approximately 400 yards off- 
shore. A pontoon barge was tied alongside for 
receiving casualties. A Jacob's ladder led from 
the barge to the main deck of the LST. On the 
barge was a small covered area that served 
as a supply shack. A number of litter bearers, 
two medical officers, and a talker to communi- 
cate with the control tower of the ship were 
stationed on the barge. LCVP\s, LCM's, and 
Amtracs bearing casualties, temporarily tied 
up alongside the barge while the medical of- 
ficer on duty went aboard to examine the 
wounded. Casualties requiring immediate at- 
tention were taken aboard the barge, where 
emergency treatment was carried out. To load 
patients in need of immediate surgery aboard 
the LST(H) a metal frame accommodating 3 
stretchers was lowered to the barge by a 
tractor crane mounted on the main deck, just 
aft of the cargo hatch. The patients were then 
brought up and lowered directly into the tank 
well through the cargo hatch, which was 
always open and was outlined by luminous 
painted lines to prevent accidents during 

About 220 patients could be cared for on 
the tank deck and another 150 to 175 in the 

troop quarters. Patients requiring an opera- 
tion were moved from the tank deck through 
the open hatch forward to the operating rooi 
The normal complement of an LST(H) was 4 
medical officers and 26 corpsmen, but 
this was insufficient. The use of LST(H)'s 
evacuation control ships although representing 
an important step forward in the chain of 
evacuation, left much to be desired. Used for 
the transportation of LVT's to the target, they 
were converted for casualty handling only 
after these had been discharged and as a 
result, were often covered with dirt and grease 
when turned over to the medical department 
The illumination on the tank deck was usually 
very poor and the medical facilities were ui 
satisfactory. The number of medical personnel 
assigned was insufficient to care for the large 
number of casualties, even when the staff 
worked day and night. On D-day, betweef 
0900 and 1530, a total of 2,230 casualties were 
evacuated by LST(H) — an average of slightly 
less than 6 casualties per minute. 



Figure 106. — Administering intravenous fluids in an abandoned Jap dugout. 

The organization of LST(H) casualty evac- 
uation control ships was as follows : 


. 1. The primary functions of these ships are: (a) To 
^control evacuation of casualties to available ships, 

maintaining adequate distribution for propei- early 
treatment of casualties, (b) To act as a tiansfer sta- 
tion for transfer of casualties from LVT's and 
C^UKW's to LCVP's where reefs intervene between 
ships and beach, in order to release LVT's and DUKW's 
for military operations, (c) For emergency evacuation 
from beaches when other ships are not available, (d) 
To expedite speedy resupply of strategic medical sup- 

plies to beaches and landing force, (e^ To maintain an 
accurate record of evacuation, for Force and Corps 
Commands. (/) To render shock therapy to those cas- 
ualties whose condition is so critical as to prevent 
further progress in the chain of evacuation. 


2. Elach squadron of transports carrying" assault 
troops will be provided with two evacuation control 
LST's. These ships are stationed 1,200 yards ahead 
of LST formation and 300 yards seaward of the Trans- 
Div Control vessel centered off the colored beach it is 
serving and directly ahead of the transport division 
to which it evacuates. Each evacuation control ship 



is provided with a 3 by 12 pontoon barge along-side as 
a casualty transfer platform and unloadin.o- station for 
those casualties to be retained aboard the LST for 
treatment until their condition warrants transfer. 

3. The TransDiv Commander will keep each evacua- 
tion control LST, serving his beaches, informed of 
ships available for casualty reception, notifying them 
1 hour in advance of those ships departing from 
transport area, insofar as practicable. 

4. Two LCVP^s equipped as ambulance boats will be 
sent from each assault TransDiv to its casualty evacu- 
ation control LST as soon as assault troops are landed. 
These boats together with the two LCVP's on each 
evacuation control LST will serve as ambulance boats. 
Ambulance boats will fly a VICTOR flag at all times. 
One ambulance boat shall be sent to each beach area 
after assault troops have landed to stand hy to land 
and receive casualties When directed by the Beach- 
master. Litter and splint exchange should be made at 
each ship to which casualties are evacuated. All other 
resupply items for these boats will be made at the 
evacuation control ship except on request of Evacua- 
tion Control Officer. 

These boats shall be equipped with the following 
prior to leaving the mother ship: 

Tarpaulin 1 

Life jackets 17 

Water canteens 6 

Struts for litter loading — 

Hospital corpsman with first-aid kit — 

Bandages, 3-inch 36 

Bandages, 2-inch 36 

Plasma, units 10 

Morphine syrettes 20 

Cotton rolls * , * 6 

Sulfadiazine, bottles 2 

Flashlight 1 

Litter units 10 

Tongue blades, box 1 

Scratch pad and pencil 1 

5. The evacuation control LST duty officer will 
keep an up-to-date record of location of all ships as- 
signed him for casualty reception. He will direct cox- 
swains of ambulance boats to ships assigned by the 
Evacuation Control Officer. He will also direct cox- 
swains of ambulance boats to exact location on the 
beach to deliver medical supplies and receive casual- 
ties as shown by beach markers (VICTOR flag). 

6. Each evacuation control LST is recognizable by a 
large white "H" painted amidships on both sides. They 
are located 300 yards directly seaward of their cor- 
responding TransDiv control vessels. They fly an over- 
size VICTOR flag- and display a GREEN light at 
night. They have pontoon barges alongside and stand 
out 1,200 yards ahead of the LST formation. 

7. Four surgeons and twenty-seven corpsmen are 
attached to each evacuation control LST. The senior 

surgeon is designated as tlhie Evacuation Control q^^ 
ficer and is responsible for proper distribution of cas, 
ualties to available ships assigned by the TransDiv 
commander. Two-section 4-hour watches will be main, 
tained, beginning at 0800 on D-day, until ships are 
relieved by orders from Attack Force Commander 
relieving at 0800, 1200, 1600, 2000, 2400, and O400.' 
The appended watch bill will serve as a guide giving 
titles, number of personnel, and times of watches. 

8. Evacuation Control LST's shall make a dispatcli 
report to Squadron Commander and Attack Force Conu. 
mander at 0900 and 1700 daily, giving a report of 
casualties on board at that time, using the following 

(Example: Bed 65 X NE 20 Total 150 X Bead 7 X 


9. Copies of Form A (copy appended) giving date, 
name, rate, serial number, and disposition of each 
casualty evacuated will be sent to Landing Force Com- 
mander (Corps Hdqts.). 

The casualty evacuation officer on the cas- 
ualty evacuation control LST(H) endeavored 
to distribute the casualties among the different 
ships so that no one transport would be over- 
burdened at any time. Unfortunately, this did 
not always work out. Sometimes the coxswain 
failed to heed the directions given him or mis- 
understood them, and sometimes when he ar- 
rived at a designated location the ships were 
not there. Some casualties spent as many as 
S hours in small craft before being taken 
aboard a ship. 

The APA, although not designed for cas- 
ualty handling, or properly equipped for this 
purpose, often bore the brunt of the initial 
casualty load from the beach assault. In the 
Iwo Jima operation, they received 4,956 
wounded by 1745 of D-day-plus-2. The exper- 
ience of APA 118 was typical of the trans- 
ports in casualty evacuation. APA 118 dropped 
anchor about 20,000 yards offshore on D-day 
and unloaded its troops on schedule. It then 
moved in to about 4,000 yards from shore and 
began discharging cargo and supplies. At 1400 
on D-Day casualties were received aboard, the 
majority of whom were severely injured and 
required emergency treatment. During the next 
few days, casualties were loaded aboard the 
ship in groups of from 3 to 75. Throughout 
much of this period, the medical staff worked 
day and night operating on and caring for the 
wounded. As a general rule the ship withdrew 
out to sea at night, but on two occasions she 



anchored about a thousand yards offshore and 
obtained protection by a smoke screen. 

The large number of wounded at Iwo Jima 
gjjiphasized the need for hospital ships, two of 
which were originally scheduled for the opera- 
l-iQii. Commencing on D-Day-plus-1, these 
ships, the SaMaritaii (AH 10) and the Solace 
(AH 5), augmented by the PiMcJxuen (APH 2), 
the Bountiful (AH 9), and the reserve hospital 
ship, Ozark (LSV 2), inaugurated a series of 
shuttle trips from Iwo Jima to Saipan and 
Guam. By 21 March (D-day-plus-30) a total 
of 4,879 casualties had been evacuated on these 

The only function of the hospital ships was 
the transportation and care of the sick and 

wounded, and if some of them could have re- 
mained in the area during the early phases of 

the operation to care for the slightly wounded, 
many casualties could have been returned to 
duty in a few days. The loss of manpower oc- 
casioned by their departure aboard hospital 
ships and transports to Saipan or Guam, would 
have been obviated. 

Some hospital ships lacked proper equipment 
for taking patients aboard (figs. 107, 108, and 
109). These ships received many boatloads of 
injured men from LCVP's, but some had no 
Welin davits with which to lift the boats to 
the ship's deck level, and the transfer of pa- 
tients had to be made over the ship's gangway. 
This slowed the rate of transfer of patients 
and as a result, boats loaded with wounded 
gathered off the gangways of the hospital ships 
and were obligsd to stand for hours in the hot 
sun with their patients unprotected. 



Figure 108. — Transferring patients from an LCV to Hospital Ship H.M.S. 


Air evacuation from Iwo Jima to the Mari- 
anas, which supplemented evacuation by hos- 
pital ships and transports, was initiated on 
D-day-plus-12 and was originally planned for 
350 patients per week. The very high casualty 
rate, however, together with the shortage of 
ships for transporting casualties, necessitated 
revision and as many as 200 a day were evacu- 
ated by air. There were times when, because 
of unfavorable sea conditions or lack of facili- 
ties alioat, air evacuation was the only means 
of getting casualties off the island. With the 
first casualty evacuation planes, there was an 
air evacuation unit, consisting of two flight 
surgeons and several hospital corpsmen who 
screened all casualties to be evacuated by air. 
By 21 March (D-day-plus-30) , a total of 2,393 
patients had been evacuated b> air. The cas- 
ualty evacuation planes also brought in whole 
blood from Guam. 

The weakness of a fixed policy for evacua- 
tion was again demonstrated at Iwo Jima 
where a ''15-day evacuation" policy had been 

established. In the early stages of the invasion, 
there was no place to segregate casualties who 
would be ready for duty in 15 days or less, 
and when hundreds of casualties were being 
evacuated over beaches that were under heavy 
enemy fire and clogRed with vehicles and equip- 
ment of all kinds, sorting was not feasible. 
Time, space, and the combat situation did not 
permit convalescent camps to be established 
and such beds as were available ashore were 
needed for those seriously wounded. 

There were a number of ways in ^^'hich the 
effectiveness of the chain of evacuation might 
have been improved. The communication sys- 
tem could have been more efficient during the 
first days. Casualty evacuation officers aboard 
the LST(H) often did not receive reports as 
to which transports were available for loading 
casualties, with the result that some ships 
received more than their share while others 
received very few. Ambulance craft experi- 
enced great difficulty in finding the proper ves- 
sels. In many cases, the APA stood well off- 



jjQj-e, and during rainy, rough, or foggy 
weather they were difficult to contact. It some- 
times occurred that by the time the ambulance 
craft had reached the approximate station 

where the transport was supposed to be an- 
chored the ship had already moved. 

Despite difficulties such as these, the chain 
of evacuation operated more smoothly than in 
any previous action in the Central Pacific. The 
use of LST(H)'s as casualty evacuation ships 
represented a most important factor in medical 
care and unquestionably saved many lives. 


The establishment of hospital facilities on 
Iwo Jima was delayed because of limited space, 
difficult beach conditions which interfered with 
the landing of supplies and equipment, and the 
constant hazard of enemy artillery and sniper 
fire. As a result, until D-day-plus-9 nearly all 
hospitalization was provided by the units 
afloat. During the early days of the operation, 
effective hospitalization was provided by four 

Medical Battalion, Company A, landed on 
D-day-plus-6, just south of Green Beach, and 
began to set up an operating room and hospital 
facilities with provision for expansion. Within 
8 hours a hospital unit with 110 beds was 
established and began to receive casualties. 
During the next few days, hospital facilities 
were expanded. 

A neurosurReon, an ophthalmologist, and a 
neuropsychiatrist were included in the staff of 
the corps medical ])attalion and the services 
of these specialists were made available for 
all troops engaged in the Iwo Jima operation. 

A detailed account of the activities of the 
Fourth Marine Division Hospital will illustrate 
the work of hospital units at Iwo Jima. On 
D-day-plus-6 the division surgeon and com- 
manding officer of the medical battalion 
located a site for the Fourth Marine Division 
Hospital, near a good road leading to the front 
lines and to the evacuation beaches. The Fourth 
Engineer Battalion bulldozed 5 long trenches, 
providing space for 4 batteries of 6 storage 
tents each, 1 battery of 3 storage tents, and 
the division medical dump. On either side of 
the road were uncovered water reservoirs. Two 

of these were used as operating rooms, one as 

a receiving room, and the other two for Head- 
quarters and Staff Medical Battalion and for 
the malaria and epidemiology control team. 
Many times while mortar shells were landing 
nearby, surgical operations were going on. The 
engineers had constructed an entrance ramp 
and erected a wooden framework over each 
reservoir, with a tarpaulin stretched over the 
framework* The hospital was receiving casual- 
ties on D-day-plus-9, and 6 operating rooms 

Figure 109. — The U.S.S. Savmritan anchored off Oki- 
nawa. Transferring a patient from a small boat via an 
elevator rigged over thie side of the ship. 




Figure 110. — Refrigerator units for the storage of blood plasma and vaccine sera. 

and 350 beds were available on D-day-plus-lS. 
It was staffed by 3 medical companies and 
surgical detachments from 2 companies. 

A division central medical supply room was 
established in the hospital area and the sur- 
gical instruments of all five medical companies 
were pooled, permitting simultaneous steriliza- 
tion of many sets of instruments, thereby ma- 
terially lessening the delay between opera- 


Because of the porosity of the soil, sanita- 
tion presented no major problem. Sunken bar- 
rels with prefabricated tops served as heads. 
The water supply was adequate, being obtained 
from water trailers. 

No outbreaks of intestinal or communicable 
disease occurred and there were no epidemics. 
Neither the interrogation of prisoners nor the 
study and laboratory findings of malaria and 
epidemic control teams revealed evidence of 
malaria, dengue, filariasis, typhus fever, 
cholera, plague, yellow fever, smallpox, diph- 
theria, or venereal diseases in serious propor- 

Supplies and equipment 

One of the innovations was the mobile blood 

bank facility (figs. 110 and 111). The main 
items of equipment were two 150-cubic-foot 

refrigerators, one flake ice machine, three 
electric generators, one 2 5/2 -ton truck, and one 
i-ton truck. The initial supply of whole blood 
was received aboard on 14 February at the Sai- 
pan staging area. Guam furnished 1,456 units, 
and ships departing from the area furnished 
an additional 406 units to the bank. Beginning 
on D-day, the facility furnished whole blood 
on request to all units ashore or afloat. At all 
times throughout the operation, the supply of 
vv^hole blood was ample. This was undoubtedly 
a material factor in saving many lives. 

The field medical unit was of high quality. 
Oxygen units were extremely valuable because 
of the high incidence of penetrating chest 
wounds. Improvised portable fracture tables 
were used to great advantage. Portable ply- 
wood operating rooms proved extremely use- 
ful ; when water seeped into some of the medi- 
cal installations at high tide, the slightly ele- 
vated deck in these huts kept them dry. 

The carbine which was issued to Medical 
Department personnel in the field for defense 
purposes was not satisfactory. It was impos- 
sible to treat a patient and handle a carbine 
at the same time; 45-caliber pistols were bet- 
ter suited for this purpose. 

The jeep ambulances proved to be the most 
valuable single piece of motor transport in 
the medical organization. The Army^s 3/4-toii 
ambulance, used by the 38th Field Hospital^ 



Figure 111. — Portable electric refrigerator for storage of biologicals, blood, and plasma. 

demonstrated its superiority over the Navy's 
i-ton ambulance for casualty evacuation. The 
Army ambulance could go anywhere that the 
Navy ambulance could go and transported the 
casualties in much greater comfort. The 
Weasels were most valuable in the early stages 
of the operation; they w^ere among the few 
vehicles able to get off the road and negotiate 
the soft volcanic sand. Many DUKW's vs^ero 
also used in the evacuation of casualties, but 
not enough were available in the early period 
of the campaign. They were capable of nego- 
tiating heavy surf without difficulty and were 
more manageable alongside a ship than were 
the amphibious tractors. For days at a time, 
when no sm.all boats were able to get through 
the surf, nearly all casualties had to be removed 
by means of amphibious vehicles, for the most 
part DUKW's. In almost every operation 
undertaken in the Pacific area, the DUKW 
saved the day for casualty evacuation. 

Medical records 

Deficiencies in the handling of medical rec- 
ords in earlier operations led to a reorganiza- 
tion of this work prior to the Iwo Jima land- 
ings. A program of indoctrination for per- 
sonnel handling records under combat condi- 

tions w^as inaugurated and the importance of 
making legible entries on emergency medical 

tags and in aid-station logs and reports w^as 
stressed. Nevertheless, reliable records could 
not be maintained during the first few days 
beer. use the battle was so intense and loss of 
personnel and equipment so great that it was 
difficult or impossible to maintain complete 
records at regimental and battalion aid stations 
or at evacuation stations. 

Dental service 

At Iwo Jima, as on all combat operations, the 
work of dental officers and technicians was 
invaluable. Dental officers, in addition to carry- 
ing out their regular duties, also assisted in 
the sick bays and operating rooms. They 
administered supportive therapy, gave anes- 
thetics and aided in identifying the dead. 


Table 21 lists casualty and evacuation figures. 

On 24 March (D-Day-plus-33) , there had 
been a total of 24,244 casualties (20,950 inci- 
dent to battle) , including 4,893 deaths. Of these 

casualties, 17,G77 had been evacuated. Casual- 
ties among medical personnel were very heavy ; 




Table 21, — Casualties and evacuation — Iwo Jima 

1. Casualties to 13 March 1945 (D-plus-22): 




3d MurDiv 

4th AlarDiv 

5th MarDiv 

Total — _ _ 

Grand total _ — _ _ 






















69 1 

2. Total battle casualties to 1800, 21 March 1945 (D<plus-30) : 

I Strength 

3d MarDiv (loss 3d Marines) 

4th MarDiv 

5th MarDiv 

VAC LanForc ( 3d, 4th, 5th MarDiv). 


Percent of total easualties. 















t cToent of 


3. Evacuated by water to 21 March 1945 (D-plus-30): 






dead and ft 
wounded * 

Samaritan 1st trip,. 

Samaritan 2d trip 

Samaritan 3d trip.. 
Samaritan 4th trip.. 

Solace 1st trip 

Solace 2d trip 

Solace 3d trip 


Piuknev (APH) 

Ozark (LSV) 

LST's (H) 

Transports (APA)-. 
Other ships 























Total . 











Evacuated by air to 21 March 1945 (D-plus-30). 2,393 ca.suaUieS. 
Summary of casualty evacuation to 21 March 1945 (D-pius-30): 

Hospital ships - — 

Other ships . 


. 4,879 



Total evacuated - 1 7,398 

1 No breakdown available. 

in one division alone, casualties of hospital 
corpsmen in each of 6 battalions exceeded 50 
percent. In 4 battalions, casualties exceeded 60 

percent, and in 1, they were in excess of 68 

percent. Battle casualties for all division 
medical personnel exceeded 25 percent. 


The offensive against the inner defenses of 
the Japanese Empire which began with the at- 
tack on Iwo Jima in February 1945 was carried 
a step further in April with the launching of 
the mighty amphibious attack on Okinawa. 
The personnel of the Medical Department in 
the attack on Okinawa now included many 

veterans of earlier campaigns, who had learned 
much in the hard school of war; now they 
had ample opportunity to apply their techniques 
and skills. 

As in previous campaigns, careful medical 

planning preceded the Okinawa operation. This 
provided for: (1) Care of the sick and wounded 



Figure 112.— Hospital tent on an Iwo Jima airfield. Note the 2 flasks of blood 
being administered simultaneously. 

(including medical care for the civilian popu- 
lation) ; (2) evacuation of the sick and 
wounded; (3) sanitation; and (4) medical 
logistics. Numerous conferences were held by 
the surgeons of the Fleet Marine Force, Pacific 
(First and Sixth Marine Divisions), the 
Amphibious Forces, Pacific, the III Amphibious 
Corps, and the Tenth Army, in order to coordi- 

nate the medical mission of providing care for 

nearly 500,000 men of the expeditionary force 
and 350,000 naval personnel aboard the more 
than 1,600 ships. 

Plans included the establishment of field 
hospitals for both the First and Sixth Marine 
Divisions (figs. 112 and 113) . Two evacuation 
hospitals were to be attached to the III Amphib- 

Figure 113. — Advanced hospital at Koza, Okinawa. Many casualties were treated here 

and returned to duty. 


ious Corps to provide specialists' care for 
wounded and to assist in the evacuation of 
casualties. Eight LST(H)'s were to be 
equipped as beach evacuation control vessels, 
4 to be assigned to the Northern Attack Force 
(the III Amphibious Corps), and 4 to the 
Southern Attack Force (the XXIV Army 
Corps). Evacuation from the beaches at 
Kerama Retto by the Western Islands Attack 
Group was to be by LCVP directly to 6 
hospital ships, 2 APH's, and 2 APA's converted 
for casualty evacuation. Two of them were to 
remain at the objective at all times to receive 
the critically injured. Casualties were to be 
moved to rear area hospitals in the Marianas, 
Hawaii, and the United States as rapidly as 
circumstances would permit. Adequate sup- 
plies of whole blood were to be provided for 
each transport. 

Medical planning was based upon experience 
gained in previous operations. The First Marine 
Division assigned a medical officer of wide 
experience in clinical medicine as the repre- 
sentative of the Division Surgeon to investigate 
health conditions during the operations on 
Leyte, Guam, and Saipan. Since in;i!iy of the 
diseases expected on Okinawa had already been 
encountered in the Marianas and Philippines, 
a study of the medical department's experiences 
in those places proved of great value. 

All units of the First Marine Division were 
instructed in the value of sanitation and the 
need for sanitary measures during combat. 
Sanitary squads were trained to operate with 
each combat team, and to assist in mosquito 
and fly control. Their work was to be supple- 
mented by that of a malaria and epidemic 
control unit. Latrines were to be provided by 
burying 50-gallon drums to about three-quar- 
ters of their height and fitting them with 
prefabricated seats in such a manner as to keep 
out the flies. 

The necessary equipment and supplies to 
bring all units of the First Marine Division 
up to standard strength were obtained from 
the medical supply facilities at Guadalcanal and 
Espiritu Santo. In numerous instances, how- 
ever, probably because of a lack of coordination 
between the various supply facilities, shortages 
made it necessary to request supplies from 


Pearl Harbor. First-aid jungle kits, which haj I 
been found to be far superior to the standard ' 
first-aid packet used at Cape Gloucester anj 
Peleliu, were available for most of the combat 
troops, but there v^ere not enough vials foj, 
salt and atabrine tablets, or bottles for fungi, 
cide solution. It was only with great difhculty 
that sufficient supplies were finally obtained to i 
equip approximately 7,000 jungle kits. Etforts ' 
to obtain adequate supplies of brandy, which 
had been found to be valuable in the treatment 
of combat fatigue, shock, and exposure were 
unsuccessful because of disapproval of requi, 
sitions by higher medical authority. Plans were 
made for the extensive use of serum albumin. 
All supplies and equipment not carried by 
combat units were dispersed in the five medical 
companies. Each infantry battalion was 
assigned 40 hospital corpsmen, permitting the 
use of two corpsmen to each platoon. Members 
of each combat unit were assigned as litter 
bearers. These litter bearers, who were dis- 
persed among the various rifle companies, 
were trained in first aid and the evacuation of 
casualties from the frontlines to aid stations. 

The Sixth Medical Battalion (Sixth Marine 
Division), debarked at H-minus-2-hours, ani 
units began landing at H~plus-2-hours. Negli-^ 
gible enemy opposition was encountered. Instal- 
lations for the emergency handling of casualties 
under field conditions were set up within 1 
hour. All medical equipment was ashore and 
the Sixth Marine Division hospital was estab- 
lished and functioning by L-day-plus-2. After 
landing, all organizations dug in, and made 
prepaiations against air attack and sniper 
fire. During the first few days the food con- 
sisted of K rations, and the water supply was 
limited. An insufficient number of blankets had 
been provided, and some discomfort was expe- 
rienced by the men because of the rapid change 
from a tropical to a temperate zone. 

A mobile surgical trailer (fig. 114) which 
had been constructed by medical officers in the 
training area, proved of great value many times 
during the Okinawa operation. 

The experiences of the III Corps Medical 
Battalion, Corps Evacuation Hospital No. 2, 
and Corps Evacuation Hospital No. 8 during 
the debarkation and landing were unfortunate. 



Figure 114. — mobile operating room directly behind the front lines on Okinawa. 

As a precaution against enemy air or surface 
action, personnel and equipment of each of 
these units had l)een eml)arked in three sections 
on different ships. In following the loading 
plan it had been impossible to embark the 
desired number of personnel with their equip- 
ment, and on several ships, only a small per- 
centage of those originally assigned could 
accompany their supplies. In consequence, there 
was an insufficient number of men to safeguard 
medical property effectively when it was dis- 
charged on the beaches, previous experience 
having proved that unloading on the beach, 
unless supervised, would result in extensive 
loss of materiel. Notwithstandingr urgent re- 
quests by the units involved and by the corps 
surgeon, medical supplies were dispersed on 
numerous landing beaches, which necessitated 
the expenditure of much effort on the part of 
medical personnel in attempting to locate and 
collect their equipment and supplies. It also 
entailed the loss of valuable time in setting up 
hospital facilities, nullified the purpose of 
combat loading, and retarded the employment 
of medical members for the care and evacuation 
of wounded. 

The Okinawa operation proved the need for 
a large pool of trained Hospital Corps person- 
nel replacements. The First Marine Division 

had 478 casualties among Hospital Corps per- 
sonnel during the campaign in southern Oki- 
nawa. Of these, 49 were killed in action, 226 
wounded in action, 17 injured, and 186 were 
sick. Dispatches for urgently needed replace- 
ments of medical personnel resulted in some 
replacements being obtained, of whom only a 
few had been in combat and had any idea of 
the duties expected of them. It was the con- 
sensus of the medical staff that the best solution 
was to order a minimum of 100 extra hospital 
corpsmen to each Marine division at least 2 
months prior to an operation. These men 
could then be trained under experienced per- 
sonnel. After training with line regiments, the 
cori)smen could be transferred to the medical 
battalion where they would be immediately 
available as replacements. 

Battle afloat 

Medical units of the fleet also made plans for 

participation in the operation. Not only Hos- 
pital Corps personnel but also entire ships' 
crews were trained in first aid and the handling 
of casualties. Battle dressing stations, first-aid 
stations, and supplies were widely dispersed 
throughout each ship. Ample medical supplies 
to meet all anticipated needs were provided 
aboard the ships and concrete barges, AK's, 



and AKS's were available for replenishment. 
Careful preparations to provide the fleet with 
fresh whole blood in ample quantities thraugh- 
out the operation were to pay liberal dividends 
in lives saved during the '^kamikaze'' attacks 
by Japanese planes, for these attacks resulted 
in the largest number of casualties the fleet 
had experienced during the entire war (fig. 

During the initial landing and assault phase 
of the Okinawa operation, while combat units 
were experiencing only light opposition, the 
ships of the Fifth Fleet and supporting units 
were being subjected to heavy and persistent 
Japanese **kamikaze'' air attacks. The careful 
plans which the medical staffs had made prior 

such an area did not exist and consequently 
medical personnel and materiel had been di^^ 
persed. The chaos and annihilation w^j^ 
indescribable. The wounded were given sucl 
first aid as was possible. Arresting hemorrhage 
was the sole objective. Only one man was take^ 
to a dressing station and he was trapped there. 
During the 2 hours that the survivors sp 
in the water, little more than encouragem 
could be administered by the medical staff. 
heavy layer of fuel oil covering the surviv 
masked injuries. The medical officer and 
uninjured corpsman (one corpsman was kill 
another had a compound fracture) swam from 
group to group giving medical aid where pos. 
sible. Even after rescue by an LCS, only emer- 

Figure 115. — Hangar deck, U.S.S. Bunker Hill — 264 men were wounded 
and 392 killed when hit by two ^'kamikazes.'* 

to this operation, while valuable, could not be 
designed to cope with ''kamikaze" attacks 
directed against small ships. 

Aboard destroyers the medical department 
could not function as a well-trained, carefully 
drilled unit because each man was required to 
render first aid when and where he could. As 
an example, the U. S. S. Morrison, a radar 
picket and a popular target for the ''kamikaze'' 
pilots, was hit by four of them in a period of 
10 minutes and rapidly began to go down. 
Any attempt to establish the main dressing sta- 
tion in a safe area on that ship was futile since 

gency treatment could be given to the Mo 
son*s 90 wounded, because the rescue craft 
immediately called upon to take aboard 
additional 25 casualties from an LSM (R) which 
had also been sunk by "kamikaze'' planes. 

The experiences of the medical staff of the 
U. S. S. Morrison and LCS were repeated over 
and over in units of the battle fleet, as the 
Japanese made a desperate attempt to force 
its retirement. Enemy planes made attacks on 
3 hospital ships during the operation. The 
U. S. S. Relief was attacked on 2 April 1945 
and the U. S. S. Solace on 20 April, but 



age was done. On 28 April the U. S. S. 
fort was hit amidships by a ''kamikaze/' 
^^r ^ 29 and wounding 33. On the same day 

I t the Comfort was attacked, the U. S. S. 
plnk7iey (APH-2) was also hit amidships by 

"kamikaze" resulting in 22 killed, 11 wounded, 
^ d 19 missing. Notwithstanding these attacks, 
the hospital ships carried on their mission 
and maintained regular shuttle trips from the 
target to the hospitals in the Marianas. 

During the early stages of the Okinawa 
operation, as a result of repeated ''kamikaze" 
attacks, naval casualties exceeded landing force 
casualties. Then it became apparent that float- 
ing hospital facilities were urgently needed at 
the objective during the night to care for the 
wounded men from ships bombed or struck 
by suicide planes. Hospital ships, under orders 
to retire each night, were not available. When 
the two converted APA's, the U. S. S. Crescent 
City and the U. S. S. Gosper^ arrived, they 
were designated as casualty ships and were 
stationed offshore to provide hospitalization 
at night. Four PCE(R)'s, also available for 
casualty evacuation from screening ships, 
proved well suited for rescue purposes. 


Casualties in the Okinawa operation through 
27 May 1945 totaled 38,420. Of these, 28,447 
were incurred by Marine and Army combat 

troops and 9,973 by Navy. The ratio of Marines 
killed to wounded was 1 to 5 ; Army, 1 to 4.25 ; 
and Navy 1 to 1. The fleet, under constant 
enemy air attack, including almost daily "kami- 
kaze" attacks, suffered severe casualties. Prob- 
ably for the first time in naval history the 
number of killed and missing exceeded the 
number of wounded. 

Medical and surgical problems 

Disease and nonbattle casualties ashore were 
never a serious factor on Okinawa. About 6 
percent of the complement became ill. The sur- 
geon, Tenth Army, during the month of April, 
evacuated personnel for the conditions listed in 
table 22. 

Table 22. — Disease conditions requiring 
from Okinawa 




D arrhca and dysentery. 


(;(.ini):it fatigue. 


Inscct-borne disease 













Ample fresh whole blood was available to 
fleet and shore units throughout the Okinawa 
operation. During April and May a total of 
36,684 pints of blood were distributed to base 

Figure 116. — The bush master. An amphibious true tor equipped as a mobile amphibious 

operating room. 



and fleet hospitals. Of this amount 12,500 pints 
were shipped by air. In the field hospitals alone, 
1,273 surgical operations were performed and 

1,057 pints of blood were used. 

The First Marine Division in this operation 
converted amphibious tractors into mobile 
operating rooms (figs. 116 and 117). One of 

these mobile operating units was ambushed, 
but its armor prevented damage to personnel 
or equipment. The ease with which the mobile 
operating unit could be effectively blacked 
out proved invaluable, for it permitted the 
surgeon to take the patient into a well-lighted 
operating room at once instead of trying to 
work with a flashlight under a tarpaulin or in 


3ff ' 

as well as of medical personnel. The amphibio^j 
tractor was also found to be useful for moving 
the collecting station or aid stations (fig. ligj 
equipment cind personnel could be placed in 
tractor which could then proceed to the new si^ 
across any type of terrain. 

The III Corps Medical Battalion, with the aij 
of a Seabee medical section, converted a dig. 
carded radar trailer into a mobile operating 
room, and on L-day-plus-1 the unit was landed 
on Blue Beach No. 2 where it functioned as an 
adjunct to the shore party medical section. It 
later rejoined its parent organization, to render 
continuous service throughout the remainder 
of the Okinawa operation. 

Figure 117. — The bush master's opei ating room in use. 

a small crowded blackout tent. During heavy 
rains and in deep mud they afforded a dry, pro- 
tected room, and the surgeon had a clean, dry 
deck on which to stand, in contrast to standing 
ankle deep in mud and water. Another possible 
use of these amphibious operating rooms as 
visualized by the medical staff (although not 
employed in the Okinawa operation) Wcis to 
bring surgical facilities to the patient, when 
evacuation of the patient to a surgical facility 
was not possible because of terrain, heavy fire, 
or the accumulation of a large number of seri- 
ously wounded in a small area. Utilization of 
the amphibious tractor as a surgical facility 
received the enthusiastic support of the line 

A valuable supplement to the hospitalizatior 
program was the operation of a rest camp 
a nearby area during the final 3 weeks of the 
campaign. This camp, an annex to the III CorM 
Medical Battalion, provided a place to whil 
physically exhausted men could be sent tc 
recuperate. They were thus removed froml 
hospital atmosphere, and often after a fet' 
days' rest could return to their regiments iu 
the line. 

Care and evacuation of casualties 

The care and evacuation of casualties at Ou 
nawa was well handled. No serious dela? 
occurred at any time, even though transporta* 



Figure 118. — Transferring the wounded men from amphibious tractor to a 

landing barge. 

tion of casualties was complicated by bomb 
craters, blown-out bridges, and torrential rains 
that made the roads almost impassable. Ordi- 
nary vehicles bogged down in many instances, 
and DUKW's and Weasels were required to 
keep the evacuation moving. Throughout the 
campaign, evacuation over the primitive roads 
of Okinawa was slow, bumpy, and shock-pro- 
ducing. In some instances, casualties had to be 

transported 30 miles to a hospital from an 
evacuation beach, but in spite of such difficul- 
ties, the Sixth Marine Division reported that 
not once did the elapsed time in transporting 
a patient from the front to the division field 
hospital exceed 5 hours, with an average of only 
2 hours. 

In order to obviate the necessity of bumping 
patients for miles over bad roads, the Sixth 



Figure 120. — Cub plane taking off from the road-runway with a Marine casualty 

on board. 

Figure 121. — Injured man receivinfir treatment aboard 

Marine Division, during its campaign in north- 
ern Okinav^a, worked out a plan for evacuating 
casualties by water. Daily an LST(H) wflj 
stationed at the nearby port of Nago and all 
patients who were in condition to be moved 
were evacuated by this means. From the divi- 
sion field hospital casualties were loaded aboard 
DUKW^s and carried directly to the LST(H), 
which then distributed them to hospital ships. 

During the latter part of the operation in 
southern Okinav^ra, extremely heavy and per- 
sistent rains rendered roads almost impassable, 
and it was difficult to move patients even a few 
miles. Moreover, the wide reef in this area, 
and rough weather, rendered the sea lanes 
perilous. In this exigency both the First and 
Sixth Marine Divisions inaugurated air evacua- 
tion by cub planes, which took off from sections 
of concrete road near their collecting stations 
and landed on strips adjacent to the division or 
corps hospitals. Thus the seriously wounded 
were rapidly and comfortably transported from 
frontline installations to hospitals where sur- 
gical specialists were available. The First Ma- 
rine Division alone evacuated approximately 
800 casualties by cub planes between 11 and 30 
June 1945 (figs. 119 and 120). Air evacuation 



Figure 122. — Wounded aboard a transport plane being evacuated to a hospital 

undoubtedly saved many lives and did much 
to boost morale. 

Daily air evacuation from Okinavvra to Guam 
was put into operation by the Naval Air 
Transport Service and the Army Transport 
Command early in April. The majority of the 
seriously wounded were evacuated by hospital 
ships, but thousands of other casualties were 
flown out (figs. 121 and 122), Thus local hos- 
pital facilities were never overtaxed. 

Number of casualties evacuated by hospital 
ships 11,731 

Number of casualties evacuated by surface 
vessels other than hospital ships (APA, APH, 
BB) 1,405 

Number of casualties evacuated by air (NATS, 
ATC) 11,771 

Total 24,907 


Medical intelligence regarding Okinawa 
placed undue emphasis on the menace of scrub 
typhus, malaria, schistosomiasis, and snake 
bite, and underestimated the danger from 
filariasis. Filariasis was present in the blood 
of 20 to 35 percent of all natives in every age 
group. Scrub typhus was not observed, which 

was surprising because the natives were in- 
fested with body and head lice. An extensive 
investigation of snails, flukes, and leeches on 
Okinawa failed to reveal any cercaria. Malaria 
vectors were found. The snake menace failed 
to materialize; only about a dozen cases of 
snake bite were reported, no fatalities occurred, 
and the systemic reactions were not serious. 

Okinawa presented many features of medical 
importance and interest, because practically 
every disease known in Japan was found there. 
Had the military forces been called upon to in- 
vade Japan, the knowledge gained at Okinawa 
regarding malaria, dengue, filariasis, diarrhea, 
dysentery (amebic and bacillary), the veiu real 
diseases, leprosy, tuberculosis, encephalitis, 
meningitis, Weil's disease, hepatitis, and others 
would have proved of great value. 

At the very outset of the Okinawa operation, 
eftective sanitary measures were instituted. 
Beachheads were sprayed with DDT from 
carrier-based planes, beginning on L-day-plus- 
3. Attached to the combat teams were sanitary 
squads consisting of 1 hospital corpsman and 19 
Marine enlisted men, assigned duty which 
included sanitation and insect control in the 
combat area and disposal of enemy dead. The 
malaria and epidemic control units attached to 
the Marine divisions performed a valuable 



service in epidemiologic investigation and in 
the control of flies and mosquitoes. 

Devotion to duty 

Examples of conspicuous heroism of medical 
personnel on Okinawa were numerous. The 
gallantry and devotion to duty of the hospital 
corpsmen was stirring, and their heroism under 
fire was recognized by appropriate awards. As 
examples are the follo\\'ing men who received 
the Congressional Medal of Honor : 

Bush, Robert Eugene, Hospital Apprentice, 
First Class, USNR. 

Willis, John Harlan, Pharmacist's Mate, 
First Class, USN. 

Halyburton, William D., Pharmacist's Mate, 
Second Class, USNR. f 

Pierce, Francis J., Pharmacist's Mate, First 
Class, USN. 

Whalen, George Edward, Pharmacist's Mate, 
Second Class, USNR. 

Williams, Jack, Pharmacist's Mate, Thirdj 
Class, USNR. | 

Lester, Fred Faulkner, Hospital Apprentice,' 
First Class, USNR. 

Medical Action ARoat 

Medical Department personnel of fleet units 
gave eflicient care to the wounded under the 
severest handicaps imaginable. Both during the 
Philippine invasion and off Okinawa, under 
bombing and "kamikaze" attacks that smashed 
their dressing stations or sank the ship on 
which they were working, they rendered heroic 
service (figs. 123 and 124). 

The U.S.S. Peeos, the last source of fuel for 
ships in the Tjilatjap area was ordered to 
intercept two destroyers that had picked up the 
Langley's 450 survivors. Transfer of the sur- 
vivors from the destroyers took place at 0400 
under adverse weather conditions. The boat- 

swain had an especially difficult task in keeping 
the motor launch steady in the heavy seas while 
the wounded were hauled aboard. Practically 
all the survivors were suffering from shock or 
exhaustion; many were injured. In the sick- 
bay the medical officer and five corpsmen 
worked unceasingly treating shock, applying 
splints, and bandaging wounds. 

Within 6 hours after the injured had been 
taken aboard, enemy bombs tore a great ho] 
amidships and started a fire in the Peeos, 
ship began to sink. Injured men in the forward 
part of the ship could not reach the ma 
dressing station, and the pharmacist's ma 

Figure 123 —First aid aboard U.S.S. Nevada after Jap "kamikaze'' attack. 

Figure 124. — U.S.S. FravkJiu after ''kamikaze" attack — ^patients bein^ 
transferred to U.S.S. Santa Fe. 

there carried on alone. To an already over- 
crowded sick bay were brought newly burned 
and injured patients. The medical officer 
describing his experience said : 

When I heard the machine and antiaircraft guns 
rattle, I knew that we had about 30 seconds before 
we would sustain another hit or near miss. We would 

treat a patient for a few moments and then drop 
down alongside him, the pharmacist's mate on one side 
and I on the other, and wait for the ship to jump. As 
soon as the ship stopped shuddering we would again 
attend the injured until the next bomb burst. Often the 
interval was less than a minute. 

After 4 hours of this we were ordered to abandon 
ship. The injured officers and men were carried from 
the sickbay up the slantinj^ deck to the side of the 
ship. Kapok-filled mattresses were lashed to those most 
severely injured and then lowered over the side 
A well man accompanied each injured man in the 
water. Men tore down doors and broke out wooden 
panels to obtain floatable supports. Others made use of 
bamboo poles which the commanding- officer had taken 
aboard before leaving Tjilatjap; one 10-foot pole gave 
support to 4 men. 

The Prro.s' went down at 1355, with no other 
vessel in the vicinity. In response to a flare set 
oif by the men in the water, one of the destroy- 
ers that had given the Langlei/s survivors to 
the Pecos that morning, arrived at the scene. 
When the medical officer and the corpsmen got 

aboard the destroyer, the chief phiarmacist's 

mate in that ship had already laid out all 
medical equipment on the table in the officers 
wardroom. It was about 0100 the next morning 
before all the men had been taken aboard and 
cared for. destroyer with 350 men aboard 
in heavy weather is not the most comfortable 
ship in the Navy, but the sick and injured 
received adequate treatment and were secure in 
their bunks." 

Casualties in fleet units at sea occurred not 

only from torpedoes, aerial bombs, and gunfire, 
but also, later, from the unique Japanese 
weapon — ^the "kamikaze" — ^the first of whose 
attacks was delivered in April 1945. 

When the Princeton was struck by a heavy 
aerial bomb carried by a **kamikaze," flames 
from the explosion caused terrific damage. Both 
the forward and midship battle dressing sta- 
tions were rendered useless; the main battle 
dressing station in the sick bay and the after 
battle dressing station also had to be evacuated. 
Casualties included 7 deaths, 92 missing, and 
191 wounded, but all patients received prompt, 
effective treatment. About 1530 the same day, 
the U.S.S. Birmingham came alongside to aid 
in salvage. A few minutes later a terrific 


explosion from the after part of the Princeton 
blew off her stern; blast, flames, and debris 
swept the Birmingham. Over half of the Bir- 
mingha m's personnel were wounded or killed by 
the Princeton's explosion. On the main deck 
alone about 150 men were seriously or critically 
injured. The executive officer wrote: 

I really have no words at my command to describe 
adequately the splendid conduct of all hands, wounded 
and unwounded. Not only was there not the slightest 
evidence of panic, but there was not a single instance 
where anything but praise could be given the men. 
Men with legs off, with arms off, with gaping wounds 
in their sides, with the tops of their heads furrowed 
by fragments, would insist, 'Tm all right, take care 
of Joe over there" or "Don't waste morphine on me, 
commander, just hit me over the head." 

At the time of the explosion, the Birming- 
ham's senior medical officer was in the U.S.S. 
Santa Fe assisting in the performance of sur- 
gical operations. The dental officer w^as among 
the first killed, and only the junior medical 
officer was available. He and the 14 hospital 
corpsmen, assisted by the officers and men of 
the ship's company, not only rendered first aid 
but also performed many surgical operations, 
including exploration of 5 patients with per- 
forated abdominal wounds, of whom 2 died. 
Of the 420 wounded patients treated, only 8 

On the U.S.S. New Mexico, a ^'kamikaze'' 
landed on the superstructure killing 30 men 
and wounding 129 others. It was not possible 
to evacuate the wounded until 18 days later. 
For the first 4 days following the explosion, 
the personnel were almost constantly at general 
quarters and under repeated air attack. This 
condition placed medical department personnel 
under a serious strain. Battle dressing stations 
had to be fully manned during the day to pro- 
vide first aid for casualties; definitive treat- 
ment, for the most part, could not be carried 
out until night. Critically wounded were put 
into an air-conditioned ward, but many of the 
seriously wounded, as well as those with mental 
illnesses, were of necessity placed in poorly 
ventilated compartments. The repeated gunfire 
produced a state of anxiety among the wounded, 
and their retention aboard the battleship had 
an adverse effect upon the morale of the crew. 
**Too much emphasis cannot be placed upon the 

importance of early evacuation of the woundej 
from a combatant ship,'' reported the 
Mexico's senior medical officer. This, he co 
sidered, was as essential as rearming or refuej 

As a direct result of the increased "kamikaz 

attacks, nervous tension was high in personnel 
in ships. Increasing numbers of men hai, 
*Vague mental complaints," exhibiting irri, 
tability, depression, anxiety, and fatigue. The 
senior medical officer of the aircraft carrier 
U.S.S. Cabot observed that the time required 
to complete various tasks had increased by aa 
much as 50 percent. Continuous action, *'kami. 
kaze'' attacks, lack of recreation and rest, aii4 
lack of replacement of personnel were all con- 
tributing factors in the occurrence of "nervous 
fatigue.'' *'The action in Lyngayen Gulf," wrote 
the commanding officer of the U.S.S. Southard, 
''was the severest that the present ship's cre\v 
had ever experienced. The numerous calls to 
general quarters, the sight of suicide attacks on 
ships in company, the necessity of staying at 
general quarters during daylight hours for 3 
days prior to S-day, and a suicide dive on our 
own ship, all contributed to the severe nervous | 
strain. As a result, a few members of the crew ! 
^cracked up.' Those who were unable to con- 1 
tinue under the nervous pressure were not ; 
'green' and untried personnel, but were menj 
who had been on board ship for a long time.i 
When the U.S.S. Maryland was struck by 
bombs 29 November 1944, practically all her 
major medical department installations and 
equipment were destroyed. However, because 
of adequate distribution of supplies to the four! 
battle dressing stations, the ability to rendefl 
efficient and effective treatment was not jeopar- 
dized and Medical Department personnel carried 
on, often despite their own serious injuries. 
The senior dental olTicer, who had received 
second degree face burns, administered to the 
wounded until ordered to bed. 

On 7 April 1945, a Japanese dive bombeij 
crashed into the U.S.S. Manikfvd, At the 
moment the plane struck the ship, medical offi- 
cers and hospital corps personnel at their battle 
dressing and collecting stations were ready to 
receive casualties. Operating tables were set 
up. Blood, plasma, serum albumin, sulfona^ 



morphine, petrolatum, splints, bandages, 
Tings, and instruments v^ere ready. Medical 
^^^^^^ tment personnel wearing flashproof cloth- 
^^^^''^immediately proceeded to the scene of 
If mage and fire regardless of exploding 20-mm. 
h lis cared for the injured, controlled hemor- 
h jre applied splints, and administered mor- 
^)hine while stretcher bearers filled out casualty 
^\ ^ ^ gven before the fires were extinguished, 
thrinjured had received first aid and had been 
vacuated to collecting stations where transfu- 
sions of blood and plasma and other supportive 
treatment were administered. At the battle 
dressing stations, a well coordinated surgical 
operating team was ready to carry out definitive 
care and treatment for the seriously injured. 

The reaction of personnel during emergency 
at times was unusual. "During all of the excite- 
ment of being hit, firing at the enemy, seeing 
mangled bodies, and wounded shipmates/' 
wrote one senior medical ofiicer, ''no one exhib- 
ited any hysterical reactions or maniacal tend- 
encies, nor was there any unnecessary shout- 
ing. Everyone rose to the occasion and per- 

formed his duty. The hospital corpsmen behaved 
with admirable calm and were too busy aiding 

the wounded to become excited. So strong was 
the fighting spirit and sense of duty of the men 
at gun stations that cases were reported of 
critically injured personnel, with a hand or 
foot blown off, carrying on at their stations." 

When the U.S.S. Pensacola was hit, 3 oflScers 
and 14 men lost their lives and 120 officers and 
men were wounded. Medical care and treatment 
were so prompt and thorough that not one 
death occurred among the wounded who sur- 
vived the first hour. Medical Department per- 
sonnel were tireless in their efforts and rested 
only when exhaustion made rest mandatory. 

When the U.S.S. Tfrrij was hit, the crew 
showed great proficiency in giving first aid to 
the wounded. Medical officers who subsequently 
received the wounded found them in excellent 
condition — hemorrhage had been checked, shock 
treatment had been given, and wounds effi- 
ciently dressed. This efiiciency in first aid was 
achieved because of the continuing instruction 
given the crew. 

Figure 125. — First aid to Filipino mother and li€r child on the invasion, beach at 

Leyte, Philippine Islands. 




Figure 126. — Hospital corpsmen with a Marine division on Saipan administering first 

aid to civilians. 

Prisoners of War and Enemy Civilians 

The military operations on the islands of the the problem of providing medical care not only 

Pacific, particularly on Saipan, Tinian, Guam, for military personnel but also for the thou- , 

Philippine Islands, and Okinawa, presented the sands of civilians on these islands, many of 

medical companies of assault battalions with whom had been wounded. About 10 percent of 

Figure 127. — Hospital facilities for enemy civilians were established at the 

earliest opportunity. 



Figure 128. — Sick call for natives in the Solomons. 

the population were sick and required treat- 
ment 125 and 126) ; tuberculosis, pneu- 
monia, diseases of the eye, and helminthic 
infections were common, as was malnutrition. 
On Tinian a 100-bed G-6 unit for civilian use 
was to have been landed between J-4 and 6, 
but this was delayed. Therefoi-e. the 2d and 

4th Marine Medical Battalions jointly set up 
a hospital to accommodate' 1,250 patients and 
made use of 2 surgical LST's for operating 
room requirements. 

On Saipan, no hospital facility was available 
for enemy civilians until 2 months after the 
island was secured, at which time the Army set 

Figure 129. — ^Wounded Japanese prisoner of war beinj^- carried aboard a V2F 
for transportation to a hospital on Guadalcanal. 



Figure 130. — Dental care for a young Majuro. 

up a 500-bed hospital. In the meantime an 
average of 950 patients a day sought treatment 
at the military government sick bay. A Civilian 

Public Affairs unit v^as landed, but the Public 
Health Surgeon and the pharmacists accoir. 
panying him had no equipment or supplie 

Figure 131. — Hospital care for natives on Majuro landing. 




than two field medical kits. To provide 
r al care for civilians required medical 
"^^'sonnel in the ratio of 2 medical officers and 
Tcorpsmen for each 6,000 population. 
J'lpanese propaganda had convinced the 
live population that the landing of United 
Qf tes forces on the island would result in their 
death or torture, but the highly efficient and 
humane treatment of the natives by medical 
)ersonnel attached to combat troops or Military 
Government hospitals (figs. 127 and 128) pro- 
vided most effective counterpropaganda. On 
Okinawa, many native children and women had 
self-inflicted wounds, which had been made in 

a desire for death in preference to capture. The 
natives were both astonished and grateful for 
the merciful attention given them. 

Prisoners of war requiring medical care (fig. 
129), were given the same treatment as our 
own casualties, and were evacuated to a Corps 
Medical Battalion, hospital ship, prisoner of 
war ship, or other ship, for further care and 

For the civilians in these islands, adequate 
hospital facilities w^ere erected with the assist- 
ance of native labor (figs. 130 and 131) and 
native women, instructed in nursing care, 
proved to be excellent nurses. 


The invasion of Normandy on 6 June 1944 
heralded the beginning of the largest amphib- 
ious landing in history. The medical logistic 
plan provided that the care of casualties from 
enemy action during the invasion was to be 
an Army commitment. Naval medical activities 
were to care for casualties resulting from load- 
ing accidents or near-shore enemy action ; they 
were to receive from the Army any naval 

casualties returned from the far shore and any 
patients who were in poor condition on arrival 
at a near-shore unloading point. The return of 
casualties from the far shore was to be a Navy 
commitment for w^hich purpose LST's were to 
be used (fig. 132). Alterations were made in 
the 106 LST's allotted to make them suitable 
for casualty handling, and each had sufficient 
medical supplies and equipment to provide sur- 

Figure 132. — LST landing men and supplies on the beach in Southern France. 



gical and nursing care for 200 patients on the 
return trip to the United Kingdom. To resupply 
them, medical supply dumps were established 
at Southampton, Portland-Weymouth, and 

It was estimated that 0.17 percent of the 
landing force would become casualties and it 

w^as planned that initially all ineff ectives, except 
nontransportables, were to be evacuated. Later 
there was to be established a policy of holding 
casualties ashore for 7 days, then if conditions 
permitted, for 15 days, and eventually for 30 
days or longer. The plan of evacuation further 
provided that: (a) Except for ineff ectives 
occurring in landing craft en route to beaches, 
for whom first aid was to be given, no casual- 
ties would be i'xaciiated seaw^ard until the 
assault battalions had landed; and (6) all sea- 
ward evacuation of wounded was to be con- 
trolled by navy beachmasters, who were to 
determine the means and the ships to which 
they should be sent. During the early hours of 
the assault on D-day, medical personnel func- 
tioned as independent units wherever and when- 
ever they reached the beach, no attempt being 

made to contact each other. Initially, 6 medical 
sections of the Sixth Beach Battalion and 3 
medical sections of the Seventh Beach Battalion 
were committed to the Omaha Beach, and 6 
medical sections of the Second Beach Battalion 
were committed to the Utah Beach (casualties^ 
among the latter : 1 ofhcer and 7 men killed anH 
12 men wounded). By D-day-plus-1, all re- 
maining medical sections of the beach battalions 
had landed on the designated l)eaches. | 

The first naval medical elements landed at 
H-hour-plus-40 miuLites. On Omaha Beach th 
military situation was such as to limit medi \ 
service to primary first aid. This situation pre- 
vailed until late on D-day. The initial casualties 
on Utah Beach were relatively light and genera' 
organization was more readily established. 

During the early hours of D-day on Utah 
Beach, all possible means of seaward evacua- 
tion w^ere used, including DUKW's, LCVP's and 
LCT's (figs. 133, 134, and 135). Jeeps fitt^ 
to carry litters were used to transport patienflP| 
to evacuation craft ; as many as 200 casualties 
per hour were loaded in this way. Most of the 
casualties were transferred to LST's, although 

Figure 133. (Foreground) Casualties being carried aboard an LST on an inva- 
sion beachi in France. 



Figure 134. — Casualty loading station on a beach in Southern France. 

in some instances patients were conveyed to 
hospital carriers and other ships, particularly 
during the early hours when LST's could not 
beach. At times it was necessary to transfer 
casualties from DUKW's to LCT's oiFshore. 
In the shore-to-ship phase any boats used in 

the amphibious operations were to be used to 
evacuate casualties from the beach, while LST's 
were to provide the main casualty lift for shore- 
to-shore evacuation. LCT's were to carry am- 
bulatory patients; transports were to provide 
casualty lifts as the military situation per- 

Figure 135. — ^Bringing the wounded, including German prisoners, to U.S.S. Texas, 



mitted; hospital carriers were to be available 
after D-day-plus-1 ; and hospital ships were 
to be used for evacuation to major ports in the 
United States. 

Converted assault LST's were the principal 
casualty carriers. The conversion was evolved 
from experiments conducted during the fall of 
1943 by the Planning Division of the Bureau of 
Medicine and Surgery jointly with the Sixth 
Amphibious Force. The basic structural 
changes provided for were: (a) Demountable 
brackets (fig. 136) to accommodate 147 litters 
arranged in tiers 3 high— 24 tiers along the 
starboard bulkhead and 25 alon^ the port bulk- 
head of the tank deck; (b) in the afterport 
corner of the tank deck one slop sink, a light 
over the sink, double electric outlet, and folding 
counter for portable sterilizer and trays, all 
enclosed by a removable metal cage ; (c) suit- 
able stowage facilities for litters and bracket 
arms on lateral bulkheads; (d) two mounting 
brackets for operating lights mounted in a 
suitable location over a mess table in the crew's 
mess room. 


Special equipment for each converted LS 
included : 

Item Number per 1^' 

Litter, metal pole 300 

Special Unit A, Emergency surgical dressing 16 

Special Unit B, pouch, medical officer's indi- ^ 

vidual equipment 4 j 

Special Unit C, pouch, hospital corpsmen's | 

individual equipment 40 

Medical resupply unit for beach battalion 

(beach bag) 1^ 

Bunk strap 400 

On D-day, there were 103 LST's in the task 
force. Of these, 54 had been structurally con- 
verted for casualty handling, the remaining 49 
being implemented only with additional medical 
personnel and supplies. The concept of pro- 
viding all LST's with the means to treat casual- 
ties proved invaluable during the initial period 
of the assault. As evacuation became organized, 
only designated LST's were assigned the evac- 
uation task. 


Figure 136. — LST showing the demountable brackets. 



Hospital carriers proved to be unsatisfactory 
f Y evacuation of casualties largely because they 
had to anchor far from the shore, were fur- 
'shed no casualty-handling equipment, and 
medical personnel embarked had had no special 
training in the evacuation of casualties. British 
hospital carriers were available but some dif- 
ficulty ^vas experienced in transferring casual- 
ties to them because the United States-type 
litters did not fit well in their Higgins-type 
ambulance boats. 

The near-shore medical facilities at Port- 
land, Plymouth, Falmouth, and Southampton 
functioned satisfactorily for the most part. One 
exception occurred at Portland, from D-day- 
plus-4 to D-day-plus-7, when 67 LST's waited 
to unload patients. Operational units respon- 
sible for the military success of the Normandy 
landings insisted on the priority of loading, 
regardless of casualties. Because of this, the 
LST's were retained outside the breakwater, 
necessitating unloading of casualties to LCT's 
from which they were transferred to other 
LCT's made available specifically for this serv- 
ice. In one period of 3 hours, 1,100 patients 
were disembarked in this manner. Approxi- 
mately 12,834 patients were unloaded at Port- 
land by P-day-plus-22, and 6,065 at South- 

Battle casualties were efficiently recorded, 

and information was supplied to the central 
recording section within a few hours after 

debarkation. By 5 July (D-day-plus-29) , 23,377 
casualties had been reported to the Service 
Force Casualty Section ; 22,455 were known to 
have debarked in England. A breakdow^n of the 
23,377 casualties showed: U.S. Navy, 2,078; 
U.S. Coast Guard, 76; U.S. Army, 17,247; 
Allies, 1,298 ; and prisoners of war, 2,678. 

Casualties on D-day-plus-114 included: U.S. 
Navy, 2,433 (363 dead and 2,070 wounded) ; 
U.S. Coast Guard, 117 (25 dead and 92 
wounded) ; U.S. Army, 41,147 (124 dead and 
41,023 wounded) ; Allies, 1,899 (5 dead and 
1,894 wounded) ; and prisoners of war, 9,911 
(4 dead and 9,907 wounded) . Of these, LST's 
carried a total of 41,035, the average casualty 
lift being 123. 

The ratio of Army to Navy wounded was 
approximately 11 to 1. The Navy received 
slightly more wounds per man, and of the Navy 
wounded a higher percentage had severe 
wounds. Burns and blast injuries, wounds of 
the head, face, and neck, and simple fractures 
were higher among Navy personnel. In the 
Army, wounds of the extremities were 13 
percent higher than in the Navy. Accidental 
injuries of the extremities were approximately 
four times higher in the Navy than in the 
Army, The percentage of chest wounds among 
Army personnel was nearly twice that of the 
Navy. The incidence of disease in the Army 
was approximately double that in the Navy. 


The Medical Department plans for the inva- 
sion of Sicily included the following: (a) Pro- 
vide medical and surgical care for all personnel 
on Navy vessels from the time of embarkation 
until they landed on the invasion beaches, 

(b) evacuate the sick and wounded from the 
beaches during the assault phase, until adequate 
medical facilities were established ashore, and 

(c) thoroughly indoctrinate boat crews in first- 
aid procedure. 

The wounded were evacuated to AP's, APA's, 
and AKA's. The average number of casualties 
for each AP and APA was 40 to 45. Army hos- 

pital facilities were operating ashore by D-day- 


About 15 hospital ships and hospital car- 
riers were available in the Mediterranean; 2 
of these were Army hospital ships and the 
remainder British and Canadian. The plan for 
their operational control by higher echelon was 
complicated and therefore a certain amount of 
confusion resulted. These ships had to be used 
for the evacuation of casualties after the trans- 
ports left the combat area, and often too much 
time was required to obtain their services or 
they failed to arrive at the appointed hour. As 


a result, Army hospitals in Sicily became over- 
loaded awaiting their arrival. 

The experience with hospital ships in the 
Sicihan operation prompted the inauguration 
of certain changes concerning their use, and 
all, regardless of nationality, were placed under 
the operational control of Allied Force Head- 
quarters. They operated on a prearranged 
schedule during the crucial period of D-day to 

Army transport planes began the evacuation 
of patients from Omaha Beach on D-day-plus-4, 
10 days ahead of schedule. By D-day-plus-10 
there was little need for hospital ships and 
LST's, and air transport proved adequate. Dur- 
ing a storm from D-day-plus-13 to D-day-plus- 
16, when it was impossible to evacuate patients 
by sea, the air transports succeeded in evacuat- 
ing about 1,890 patients. By D-day-plus-17, air 
evacuation was used almost exclusively, except 
for ambulatory patients who were evacuated 
by ship. 

The Commander of the Sixth Amphibious 
Force made the following comments regarding 
Medical Department facilities in the Sicilian 
invasion : 

1. The methods of handling casualties seemed 

2. Further training of boat crews in the 
use of casualty handling equipment was indi- 

3. First-aid training seemed adequate — ^the 
majority of patients received on board were in 
good condition. 

4. The number of medical personnel in all 
echelons was adequate. 

5. Medical personnel in transports, although 
very busy during and immediately following 
the action, could possibly have handled more 

6. Dental officers were not fully utilized in 
the team play. 

7. The number of Hospital Corps ratings 

w^as sufficient for this operation. With a capac- 
ity load of casualties, their services, of neces- 
sity, would have been more restricted. 

8. Evidence of the need for more intensive 

training of hospital corpsmen in transports was 
apparent. Every vessel carrying a medical 


officer should have one operating room technU 
cian and each APA should have two. These| 
technicians should receive their training prior? 
to being assigned to duties afloat. 

9. Medical supplies and equipment on hand> 
were adequate for needs, and in most instances* 
would have been adequate for a capacity load. 

10. Medical preparations for this operation 
were generally excellent throughout the force. 

11. What few deficiencies were noted or com. 
plained of in the vessels afloat, could be traced 
to a failure on the part of the senior medical 
officers to comply with directives. In a few 
instances, there appeared to be lack of fore- 
sight and imagination. 

The following comments regarding converted 
LST's were made by the Force Surgeon: 

1. Toilet facilities on the tank deck were 

2. Structural factors made transporting of 
patients in litters into troop spaces difficult. 

3. The top tier of stretcher racks was inac- 
cessible owing to its height from deck. 

4. The platform at the afterend of the tank 
deck was located directly below the forced draft 
ventilators ; this created undesirable air move- 
ment and precipitation of moisture in the sur- 
gery area. 

5. Future alterations should include openings 
from the tank deck into the troop spaces. 

6. Improvement should be made in sanitary 

7. Better access should be provided for the 
handling of litters. 

8. The receiving ward, wash room, and oper- 
ating room should be located in the troop spaces 
with entry and egress provided to the tank 
deck. / 

9. Demountable ladders should be provided^ 
to the escape hatches. 

10. Permanent stowage space should be allo- 
cated in each ship for such supplemental med- 
ical materiel as may be authorized. 

Hospital carriers (British type) 

Comments : 

1. Attached ambulance boats were not 
adapted to carrying Navy standard pole litters 
and were difficult to load. 



These vessels had no casualty-handling 
: j^gj^t other than that which was required 
^^"hoist their own special ambulance boats 
5or unloading casualties. 

3 Medical personnel in these vessels had 
no special training for the task. 

4 In the operation, their movements were 

controlled by the British Ministry of War 
Transportation, a fact which led to much con- 
fusion and materially interfered with efficient 

5. In spite of the difficulties listed above, 
between D-day and D-day-plus-11, these vessels 
completed 6 trips, evacuating approximately 
2,272 casualties. 


The following observations were made during 
the operations at Salerno (fig. 187) : 

1. The long distance to the medical store- 
house at Casablanca made barter with the Army 
and other ships in the vicinity the most feasible 
method of securing supplies. Fortunately, an 
excess of materiel at Arzew was sufficient to 
meet some of the immediate needs. 

2. Commanding officers in some instances 
failed to acquaint the medical officer with the 
plan to be followed. 

3. Medical reports were not always received 
after the operation, and often those received 
showed a complete lack of familiarity vdth the 

4. There was marked congestion on the 
beaches. In some instances the medical beach 
party was set up too close to the main road, 

and too near the unloading areas, which might 
draw aerial attacks. The only marking, a 
vertical red cross which had been promptly 
spread on the ground near the shelter, made the 
medical station even more readily discernible 
from the air. 

5. Sandbag protections should have been 
more suV)stantial and high enough to protect a 
man seated on the ground. These protective 
areas should have been large enough to enclose 
20 patients and all medical personnel. Multiple 
small enclosures were found to be preferable 
to larger single barriers. 

6. The work of the beach medical officers 
(fig. 138) was carried on with a high degree 
of skill and courage. Prompt treatment was 
accorded all patients, including some civilians, 
all of whom should have been treated ashore 

Figure 137. — Landing supplies on the beach at Salerno, Italy 

258015—58 10 

Figure 138. — Rendering first aid on the invasion beach. 

and not aboard ships, as happened in a few 
instances. Patients often were sent to ships 
not equipped for their care. The evacuation of 
patients to any ship available was not good 
practice, because on a small ship with limited 
personnel and equipment the care that could 
be given was no better than that available on 

the beach. Evacuation of patients from shore i 
to ship during the period between the depar- 
ture of transports and the arrival of hospital 
ships was considered undesirable, and beach, 
medical officers should have been prepared to 
provide treatment for patients until proper 
facilities for evacuation became available. 

Dental Officers' Experiences in Battle 

During the war dental officers showed great 
professional capability and ingenuity under all 
environments. When they were prisoners of 
war, they made alloy for dental amalgam by 
filing the Philippine pesos (these had to be 
smuggled in), and extracted mercury by heat- 
ing calomel. Sterilizers, chairs, and cabinets 
were constructed from junked material, and 
dental instruments were fashioned from many 
items in everyday use. 

The professional abilities of the dental officer 
are exemplified in the following exerpts from 
their letters to the Bureau : 

U.S.S. Vincennes 

During the battle, the sick bay was destroyed by 
gun fire and the senior medical officer and all the 
corpsmen except one were killed. It is of interest to 
note that the man on the operating table receiving 
treatment at that time escaped from the compartment 

and survived. Casualties of various types came to my 
dressing station for medical treatment. Many were 
burned, one was without an arm, one crawled in with 
his leg dangling and his face and arms burned. 

While we were administering first aid (whiclh con- 
sisted mostly of supplying battle dressing, stopping 
hemorrhage, and relieving pain), our compartment 
received direct hits from enemy shells. Later, the ship 
listed and the compartment began filling with water. 
I sent a metalsmith,, who had just been treated for 
minor burns, to find an escape hatch while the one 
remaining corpsman and I moved the medical supplies 
and the patients away from the inpouring water. An 
escape hatch was found in the compartment forward 
and through it we hoisted all the unconscious patients. 
Upon my arrival topside, I found that the ship had 
been abandoned. I walked across the starboard side of 
the ship, which was now facing skyward, and slid 
down into the water. Upon looking back and before 
a minute had passed, I could see the ship^s stern point- 
ing sharply into the air and then it quickly disap- 
peared beneath the surface of the water. 



d and given first aid. Before abandoning ship, I 
Docketed morphine syrettes and burn jelly, both 
which were used to treat the wounded aboard the 
ff Soon after daybreak we were lescuod by the 
t over Mugjord, The wardroom in this ship was 
verted into an emergency operating room and the 
^^"ously wounded were treated. All members of the 
jledical Department who were not seriously injured 
gave treatment to men? 

U. S. S. Sohice 

This report will deal briefly with maxillofacial in- 
A few statistics will be presented, although the 

on finding a raft, many wounded were lifted 


resent an unfair minimum, for there were 

figures repr 

considerably more maxillofacial injuries embarked on 
this vessel than the figures indicate. The reason for 
the discrepancy was that frequently casualties were 
brought aboard with a diagnosis of multiple wounds, 
ai^cj in these patients the treatment of thoracic, ab- 
dominal, or intracranial wounds took precedence over 
the maxillofacial injury. Critically ill men were given 
minimum or no maxillofacial treatment; in many of 
these patients the dental officer didn't even see the 
patient because the maxillofacial injury was of sec- 
ondary importance. 

The figures in table 23 indicate the number 
of maxillofacial injuries treated in the Solace. 

Table 23. — Maxillofacial battle casualties treated in 
the *'Solace'* 

Maxilla and/or 

Operational theater 


malar bone 









Guam (2 operations) 










Mandibular fractures were three times more com- 
mon than maxillary fractures. Often, a patient had 
extensive lacerations of the face, with exposure of the 
antrum of Higihrnore or a parotid fistula, and yet the 
maxilla escaped fracture. Simple fractures of the 
alveolar process usually presented no problem other 
than the decision whether to extract the teeth involved 
in the fracture. The most difficult to handle were com- 
minuted fractures of both jaws. Fortunately, these 
were relatively uncommon. Chemotherapy was rou- 
tinely employed; an attempt was made to maintain an 
optimal blood level of penicillin and sulfadiazine, using 
20,000 units of penicillin intramuscularly every ?> 
hours, supplemented by sulfadiazine, throughout the 
critical period. Penicillin and the sulfonamides were 
a large measure directly responsible for the great 
reduction in infections. Even where infection could be 

anticipated because of the necessity to work with only 
the most meager asepsis, little serious infection oc- 

When this vessel functioned as a fleet station hos- 
pital (at Manus and Ulithi), the dental service and 
EE NT were the most overworked departments. One 
of the most frequent messages received was a request 
for so many dental appointments for such-and-such 
ship. It became quite obvious that here was an ex- 
cellent indication for the expansion of operative and 
prosthetic facilities. More of this type of dentistry 
might have been concentrated at fleet anchorage; at 
no time were there enough dental officers in this area 
to meet the demand. 

The maxillofacial surgeon was particularly useful 
in a hospital ship during the embarkation of fresh 
casualties and the subsequent evacuation trip to the 
nearest base hospital. He could institute early treat- 
ment; this was particularly important. He was iieeded 
on hospital ships but the greatest need for his services 
was at base hospitals established near the action the- 
aters. Here elective treatment could be instituted, and 
definitive work could be carried out at a State-side 
hospital. It was important fully to organize early 
treatment in maxillofacial injury. 

Over 60 percent of our patients were victims of one 
form or another of high explosive fragmentation shells. 
Other types of traumatizing agents were: {(i) Bullet 
wounds (about 30 percent); (6) operational trauma 
(about 3 percent); and (c) miscellaneous trauma, such 
as from 6oo6^ traps (about 2 1 percent). 

I was impressed with the many tracheotomies per- 
formed right on the beachhead in the instance of 
maxillofacial injury. The uneventful manner in which 
these patients recovered from tracheotomy sold me 
on the benefits of this operation. All patients who 
had a tracheotomy were comfortable and resting well 
in spite of gross swelling and damage to facial tissues. 

Another and more dramatic first-aid surgical pro- 
cedure frequently instituted by the battali(jn medical 
office)' in the frontline, to check seveie hemorrhage 
in facial injury, was the ligation of the common 
carotid artery and tihe internal juglar vein. I thought 
the ligation of the external carotid might have solved 
the problem in a patient brought to my attention, but 
I didn't fully realize the difficulty of dissecting and 
identifying anatomical structures in a bleeding pa- 
tient while both the physician and the patient were 
under enemy gunfire. It was considerably more ex- 
pedient to locate and ligate the common carotid artery 
than it was to dig for the external carotid branch. 
After all, the operation was a heroic, lifesaving ges- 
ture. In two of these patients T saw the clearly defined 
signs of Horner's ocular syndrome and throughout my 
entire period of observation the symptoms did not 
improve. However, the patients were very much alive 
and were undergoing maxillofacial treatment. 

In the large majority of comminuted fractured jaws, 
it was the general policy to establish adequate drain- 



age as soon as possible. For this purpose a Penrose 
drain (rubber, through and through) was usually the 
method of choice. When a facial bone was exposed, the 
tissues were not sutured. 

It was particularly desirable to have all dental pa- 
tients concentrated in one ward. The psychological 
benefits alone were indications for setting up such a 
ward. These patients prefer to remain together. They 
wear similar types of appliances and bandages and 
submit to similar types of treatment and medication. 
A nurse or senior corpsman is always on watch to 
supervise medication and diet, and in other ways fol- 
low out the maxillofacial surgeon's orders. 

The Navy Dental Corps has accomplished in a 
creditable manner a task never before attempted. How- 
ever, it is suggested, in the event of future emergen- 
cies, that: (u) A larger Reserve Corps be main- 
tained; (b) essential dental treatment be accomplished 
in the training and embarkation areas; and (c) greater 
attention and more practical instruction in oral hygiene 
be given naval personnel. 

U. S. S. Mindanao 

At the time of the explosion I was sitting at my desk 
in the dental clinic, situated far forward on the star- 
board quarter below the main deck. My dental assistant 
was preparing a tray for surgery. At the sound of the 
first explosion no one moved; we were too stunned. 
Somehow one got the feeling that the bulkheads were 
caving in. 

After the second explosion I thought the ammuni- 
tion magazine directly below the next compartment 
forward (sick bay) had exploded. The explosion was 
so loud I was certain that it was somewhere within the 
ship. I dashed out into the main passageway; it was 
jammed with men. Then came the third and fourth 
reports in rapid succession. I had expected at any 
second to hear the general quarters sounded. I started 
for my battle dressing station below deck just forward 
of the fantail. When I reached the ladder leading 
up from the crew's forward berthing, I could go no 
further. The passageways were packed with men. I 
dashed up the ladder and started running over the 
topside. As I ran I noticed big holes in the deck 
where 8-inch shells had struck. I saw a seaman, a 
young man who had sung with our orchestra, lying near 
the ladder leading to the sickbay. He had been 

Not until I had reached the quarterdeck did I know 
what had happened. I looked across the bay; the Mount 
Hood had disappeared beneath the surface — 14,000 tons 
of steel had sunk in less than 6 seconds. 

The medical supplies from the midbattle dressing 
station locker were broken out. I set up a first-aid 
station near the gangway on the quarter-deck, using 
a fire and rescue gear chest for a table and electrical 
outlet boxes for medicine and bandage trays. Patients 
began coming over the side in a steady stream, some 
on stretchers, some ambulatory. 

The most critically ill patients were sent for^4 
to the sickbay where our ship's surgeon was ali^H 
busily operating. The slightly injured were treat^B 
the first-aid station. Two pharmacist's mates 
ships alongside were designated as my assistant^B 
a very short time word was passed that the si(^H 
the treatment room, and the medical passagi^H 
were filled. Patients were then laid out on deck ii^H 
Chief Petty Officer's mess, and soon that too b^^H 
filled. Finally no more patient*s could be accommo^B 

The first major injury treated at our first-aid st^H 
was a fractured femur. An "M" on the forehead^H 
cated that morphine had already been administJBI 

so the leg was slipped through a Keller-Blake splon' 
and made secure. The patient was then removec' 
from the improvised operating table and placed 
the deck. 

The next patient had a long scalp wound. His faee 
looked chalky. His mouth twitched a little and he died 

Many of the victims were so caked with dried ot 
as to be hardly recognizable as human beings. Soiih 
had been blown off the decks of their ships, later ! 
be lifted into lifeboats from the sea of oil. At one tin> 
I had two patients lying on the deck with tourniquet 
about their legs — each had severed arteries. One ma: 
had an ear missing, another a leg severed at tfhe shoe 
top. Facial and head injuries were numerous. AIl^ 
wounds were cleaned, painted with merthiolate, dusted 
with sulfanilamide powder, and dressed. 

U. S. S. Cascade (Destroyer Tender) 

Aboard the Cascade, a space of 24 by 14 inches with 
three ports was provided on the portside amidships, 
main deck, for the dental department. The office was 
equipped with two Ritter Units, Ritter chairs, Weber 
x-ray, air compressor. Castle lights, two desks, and a 
large steel cabinet. An extra steel locker was obtained 
so that all dental material could be stored and secured 
in the dental quarters. 

We arrived in Pearl Harbor 19 June 1943. The 
tremendous amount of dental treatment needed by 
destroyer personnel was immediately apparent. The 
crews of destroyers and personnel of shore based 
ComDesPac were cared for. 

The ship left Pearl Harbor in November 1943 and 
proceeded to Funafuti in the Ellice Islands. Here the 
need of dental treatment for personnel of destroyers, 
tankers, AK's, LSTs, and shore based SeRons was 
tremendous. The lack of small boats for transportation 
from those ships without dental officers to the three or 
four ships that did have dental facilities prevented 
or delayed the treatment of personnel badly in need of 
dental care. 

At Kwajalein, Marshall Islands, the same situation 
as to dental treatment prevailed. We left Kwajalein 
on 20 May for Majuro, wliere six Japanese civilian 
prisoners were brought aboard for dental treatment 



. i\ It was apparent that they had received no 
^^^tal care whatever. 

^^n the Wisconsin, which had a complement of 2,739 
gj-s and men, it was interesting to note that 197, 
^^^^ pj.Qximately 7 percent, showed oral fusospiro- 
tosis, and 119, or about 4 percent, showed gingivitis 
^ ^varying form. A reduction occurred in the ensuing 
ths- other factors than treatment and educational 
^^cedure were considered responsible for this. Among 
the factors were: No contact with civilians, mineralized 
water, and alcoholic beverages. 

\ system of sterile treatment procedure had been 
adopted in the Dental Department. Although it was 
agreed that this method was not perfect, it still was 
considered to be superior to routine procedures pre- 
viously employed. This was one factor that led to the 
decision to use the dental office for the treatment of 
minor head and neck injuries, in addition to jaw 
fractures. By so using the dental office, the sick bay 
could be relieved of much congestion during the times 
when hits were being made on the ship. 


At the time of the Pearl Harbor disaster, I was 
with the First Marine Division, Fleet Marine Force, 
then encamped in tents at New River, N. C. At this 
time the tables of organization allowed one dental 
officer to each regiment and medical company, and 
one for Headquarters Company, Headquarters Bat- 
talion. With a full division of three infantry and one 
artillery regiment and five medical companies, this 
allowed 10 dental officers for a reinforced division of 
20,000 men. There was no allowance for a division 
dental officer, so I was attadhed to Headquarters Com- 
pany, Medical Battalion, as a spare. 

The equipment, both medical and dental, consisted 
of World War I field units in a sad state of depletion 
and disrepair. A new supply table had been issued, 
however, and the task of disposing of the old units 
and fitting out the medical and dental departments with 
full field equipment according to the new supply table 
was given to the Division Dental Officer. The new 
supplies were very difficult to obtain, and it was not 
until just before embarking for overseas in July 
1942 that all medical and dental units were completely 
equipped and adequate reserve materiel was on hand. 

Later, a field operating light was added to the dental 
unit, and each dental officer was also equipped with 
a field unit which included an electric engine, a Castle 
field light, and a foot engine for use in case of 
current failure. A portable field generator supplying 
current was included in the units issued each Regi- 
mental Medical Unit, Medical Company, and Headquar- 
ters Company, Headquarters Battalion. 

The dental condition of the troops was deplorable. 
The few dental officers attached, even by working 
continually, could not hope to correct the condition 
of the large percentage of the personnel. The situation 
^as not to improve, for with the entry into the war. 

emphasis was on training, movement overseas, and 
combat conditions. Arrangements were made with the 
Army at Camp Davis, 50 miles south, to care for the 
few prosthetic dental cases, because a field prosthetic 
unit was not included in the Division medical equip- 
ment at this time. 

Arriving in Wellington, New Zealand, in June, 
two dental units were set up in a small temporary 
hospital near the docks, which had been taken over 
from the New Zealand Army, most of whose per- 
sonnel were in the Far East. 

Two more units were put in operation at Paeka- 
kariki, 40 miles to the north, where feverish construc- 
tion of a camp was underway in the cold rains and 
mud. Only emergency treatment could be attempted, 
because all hands were busy day and night moving 
gear from ^hips to camp — only to reverse the pro- 
cedure when the rest of the division arrived and we 
were all embarked for Guadalcanal (22 July 1952). 
A typical tent-type dental clinic is shown in figure 

The dental officer attached to Headquarters Batta- 
lion was left with the rear echelon at Wellington. The 
dental officers attached to the First, Fifth, and Eleventh 
Regiments and A, B, and C Medical Companies; in 
addition to the Division Dental Officer, embarked. An 
accident aboard ship on 3 August prevented the B 
Company Dental Officer from landing, leaving six 
dental officers to hit the beach at Guadalcanal on 7 
August. After 3 weeks the failing eyesight of the 
dental officer in A Medical Company necessitated his 
evacuation. The five remaining still proved ample to 
man the three offices we managed to set up and keep 
in operation through the ensuing months of bombings 
and shellfire. 

The Division began withdrawal from Guadalcanal on 
9 December 1942. The following 6 weeks in the brush 
outside Brisbane, Australia, were a nig'htmare of rain, 
mud, lost and misplaced equipment, and inadequate 
supplies. Sufficient equipment was finally located in 
the scattered dumps to establish offices in five areas. 
Some supplies were secured from the Army, including 
a field prosthetic unit. Then came the order to pack 
up for Melbourne, and the usual loss of equipment 

At Melbourne, camps were established in and around 
the city and dental officers assigned accordingly. The 
rear echelon, still well supplied and equipped, had 
rejoined the dental officer. All division reserve medi- 
cal and dental supplies and equipment originally left 
in Wellington, New Zealand had been moved to 
Noumea, New Caledonia, and were now unavailable 
to us. 

It was during this noncombat status of the Division 
that a need for dental officers to take care of the 
great load of work became apparent. Recommenda- 
tions made through the Division Surgeon later resulted 
in the increase by 20 of the Marine Division Dental 
Officer Complement, the official recognition of a Di- 



Figure 139. — A Navy dentist administering dental treatment in one of the typical 
tent-type dental clinics at an advanced base. 

vision Dental Officer, and the addition of one field 
prosthetic dental unit to the equipment of a Division. 

Another Marine Report 

Reported to Medical Field Service School, Camp Le- 
jeune, New River, N. C, 1 June 1943. The instruction 
received here aided immeasurably in understanding 
problems — ^military and medical — to be met in the 

Reported to *E* Company, Fourth Medical Battalion, 
Fourth Marine Division, 24 July 1943, leaving North 
Carolina for Camp Pendleton, Calif., 11 August 1943. 

An extensive training program was undertaken dur- 
ing the remaining months in the states. Working in 
conjunction with the medical officers, the dental officer 
instructed corpsmen in first aid, field hospital organi- 
zation and function, and medical problems to be faced 
in combat. 

Debarked from San Diego for Roi-Namur, Kwaja- 
lein, Marshall Islands. Medical companies functioned 
on ship because of the lack of land area during this 
operation. Transports in the lagoon received wounded 

from the beach evacuation stations. Dental officer 
screened patients and car^d for all oral and facial 
injuries, and treated preoperative shock. 

Duties With the Ma/rim Corps 

The following observations were made : 

1. Dental officers assigned to the Marin© 
should have a good working knowledi 
of anesthesia. 

2. Dental needs of personnel in Marine Divi- 
sions should be completed before their 
assignments in the field. Because of the 
constant movement of these divisions, 
innumerable difficulties were encounterec 
in setting up dental facilities. If all neces- 
sary work were done prior to leaving 
the continental limits, the number of 
dentists assigned to a division could be 


Chapter III 

Mobile and Base Hospitals 

Lucius W. Johnson, Rear Admiral (MC) USN (Retired) 

The rapid movement of large military forces 
with their housing and equipment by land, sea, 
and air has been the subject of study by mili- 
tary leaders for many years. The military sur- 
geon, on his part, recognized that medical and 
hospital facilities must be just as mobile as the 
forces they were designed to serve, and that 
completely equipped and fully staffed hospitals 
must accompany troops wherever they might 

Mobility as a characteristic of hospitals has 

always been elusive. In order to determine what 
supplies, equipment, transportation, organiza- 
tion, and administration would be best suited 
for k mobile unit, the Bureau of Medicine and 
Surgery in 1940 set up U. S. Naval Mobile 
'hospital No. 1 as an experimental unit. Trial 
and error seemed to be the only logical basis 
on which to begin the quest for mobility. As 

this required a willingness to confess errors 
at any point and to begin again, we were con- 
tinually retracing our footsteps and starting 
out on a new angle. A great deal of progress 
in mobile hospital design was nevertheless 
achieved, although most of the problems still 
remained unsolved at the end of the experiment, 
to provoke our successors to continue the 

Beginning in September 1940, materials for 
the hospital were assembled at the U. S. Naval 
Medical Supply Depot, Brooklyn, N. Y. While 
that work went on the carpenter's gang were 
busy building tent floors, marking the parts of 
the prefabricated buildings, and designing 
bases for the many machines. On 5 October the 
hospital was officially commissioned and the 
watches set. This gave it a definite status 
although it was still but a jumble of boxes, 



Figure 141.— U. Naval Mobile Hospital No. 1. 

barrels, bales, and crates on Pier 65, North 
River. Twenty days later the materials and 
the personnel were embarked for the U. S. 
Naval Station, Guantanamo Bay, Cuba. Unload- 
ing, which was begun early on the morning 
after arrival, continued without interruption, 
night and day, until it was completed (fig. 140) . 

One fact which remains indelibly fixed in 
the minds of those who have taken part in an 
expedition of this sort is the enormous amount 
of physical work required to get a hospital 
erected and in operation. One husky 6-footer 
among our hospital corpsmen straightened his 
weary back after 16 hours of strenous work, 


Figure 142. — Erecting one of the sectional buildings. 

■■^^'-^ --rr.'':.^ MOBILE AND BASE HOSPITALS 


the fi^^^ ashore, and groaned, "I didn't 
jyiow that the birth of a hospital involved such 
painful labor." 

pitching, clearing, leveling, excavating, erect- 
ing tents, making tent floors, moving several 
thousand boxes, bales, and crates, and con- 
structing foundations for machinery and foot- 
jngs for buildings, all called for labor around 
the clock. In spite of the arduous work, a boy- 
scout enthusiasm pervaded everyone. Com- 
mander Thomas B. Magath (MC) USNR, of 
the Mayo Clinic, was present as an observer. 
In his report he expressed what all of us felt 
about the spirit and versatility displayed by 
the enlisted men : "Probably the most interest- 
ing part of the whole experiment was to observe 
the efficiency of the hospital corpsman. Not only 
was he able to be a good mechanic, electrician, 
or plumber, but he was able to clear land of 
virgin brush, lay water lines, erect shower 
baths, build concrete foundations for buildings 
and, of course, carry out with usual naval pro- 
ficiency laboratory and operating room tech- 
niques and general nursing care. These men 
immediately gain respect and admiration'' 
(figs. 141, 142, 143, and 144) . 

A large number of artificers were attached to 

our unit. Without them to show the way and 
to figure out the technical details of construc- 
tion, the building of the hospital would have 
been delayed indefinitely. In the group were 
several older men from the Fleet Reserve, all 
of fine character and great ability in special 
lines. They were so determined that none of the 
younger men should do any more work than 
they did that they would not admit any fatigue. 
As a result several of them broke down and 
became so sick that they had to be sent home. 
Those able and devoted older men need to be 
watched, so that their services may not be lost 
through excessive fatigue. 

Medical and dental oflScers did many things 
that were far removed from their normal 
duties. For 2 months the chief of the medical 
service was in charge of erecting tents. The 
urologist had the job of sorting several thou- 
sand packages and locating lost articles. The 
laboratory officer laid water pipes and was the 
best man in the outfit with an air hammer. Our 
radiologist was in charge of digging latrines 
and clearing the brush from the site. The psy- 
chiatrist became expert in planning and build- 
ing shower baths. All of them worked at these 
unfamiliar tasks with the same enthusiasm that 
they gave to their usual duties. 

Figure 143. 

-Erecting another of the sectional buildings. 



Figure 144.— Aerial view of U. S. Naval Mobile Hospital No. 1. (1) Enlisted staff 
quarters, in tents. (2) Recreation area; niovie shack and screen; volleyball 
court. (3) Tent wards; 25 patients in each ward; utility tents at ends of 
wards. (-1) Medical ward, in prefabi-icated building. (5) Operating' room at left. 
At right, surgical ward in prefabricated building. (6) Tent surgical ward, 
operating room at right. (7) Building containing dental clinic, laboratory, 
pharmacy, and cold storage. (8) Five mess halls in prefabricated buildings; 
galley and water heaters between buildings; bake ovens at right. (9) X-ray 
building, with generator shack at right. (10) Two 20-kw. generators. (11) 
Maintenance area. Electrical, machine, and carpenter shops, lumber pile. (12) 
Administrative area. Offices on each side of central flag pole. (13) Storage and 
issue tents; bag room; bulk stores under tarpaulins. (14) Incinerator, hillside 
type. (15) Laundry. (16) Officers' quarters. (17) Water-purification plant and 
storage tanks. 

The civil engineer proved to be particularly 
valuable. We were fortunate in having a young 
Reserve officer with wide experience in all 
kinds of construction. He displayed zeal and 
imagination, allowing nothing to interfere with 
his determination to build whatever we wanted. 

As a part of the mission of the Medical De- 
partment of the Navy, the unit was assigned 
the following definite task : 

1. To erect a hospital. 

2. To provide the best possible care of 

3. To keep the hospital as mobile as possible. 


To keep the Bureau of Medicine and' 
Surgery informed of all the information 
we might gain, so that improvements 
could be incorporated in plans for future 
mobile hospitals. 
Ever since the Spanish-American War, there 
has been intense interest in the loading of ships 
for military expeditions. On that occasion the 
transports sailed away from the beaches at 
Daiquiri and Siboney, in Cuba, as soon as the 
soldiers had been landed. Still in the holds of 
the ships were the field hospitals, field guns, 
and ammunition which were to be desperately 
needed during the battles which followed. This 



k of foresight was the subject of bitter com- 
nt by both Clara Barton of the Red Cross 
^ d Col. Theodore Roosevelt. When the latter 
became President, he directed that a careful 
study of the matter be made, from which stems 
our present methods of last-in-first-out stowage 
of materials in ships carrying military expe- 

For this mobile hospital a plan of loading 
was worked out that would give us at once the 

things that would be urgently needed on land- 
ing. These carefully laid plans went so far 
awry that it would have been ludicrous if it 
had not been so serious. The reasons are worth 
telling, so that others may avoid them. By 
arrangement with the ship's officers, the tents, 
tools, ranges, latrine boxes, and other essentials 
were placed in the top layer of No. 6 hold. We 
saw the hatch closed and left for the night, 
serene in our feeling of intelligent planning, 
but the stevedores worked long hours that 
night stowing piece lumber on the hatch cover 
of that hold. Nothing moves more slowly than 
piece lumber, so the work of unloading No, 
6 hold was not started until late on the day of 
arrival. Even then, the order was to move all 
heavy articles first so that the dock could be 
kept clear. As a result, the first to be unloaded 
were caskets, ward furniture, and other objects 
that would not be needed for several weeks. 

The limited docking facilities further com- 
plicated our situation. It was necessary to clear 
the dock quickly, to make room for another ship 
due to arrive shortly. All available trucks were 
pressed into service to move our goods, which 
were taken to the hospital site about 2 miles 
away, too rapidly for our men to identify or 
segregate them. Thousands of boxes, barrels, 
crates, bales, and cartons were dumped pro- 
miscuously about the 8-acre site. This work 
continued until after midnight. For a time, a 
motor-driven flood light was provided, but this 
soon ran out of gas and for the greater part of 
the night the work was done in darkness. No 
intelligent supervision was possible. This indis- 
criminate dumping meant that many days of 
labor by a large gang were necessary to find 
the things needed first. Thousands of packages 
had to be handled repeatedly, thus wasting 
hundreds of hours of manpower. Some of the 

most needed items were not found until well 
into the second week. 

These details are mentioned to show how 

unforeseen complications can nullify the best- 
laid plans. Looking back at the experience, the 
thing that stands out most prominently is the 
great number of fine ideas that went wrong. 
They looked foolproof and wonderful as we 
talked them over but when we tried them out 
they did not work. Eventually, we adopted as 
our slogan, '*How could we be so dumb?'' I 
remember one case marked ''Med. in glass 
bottles" and another labeled, "Delicate instru- 
ments. Handle with great care.'* Both of these 
were moved gingerly, and were the first articles 
to go under cover when a tent became available. 
When they were opened, the former was found 
to contain a coil of rope and the latter 6 mop 

On the thirteenth day after arrival, the hos- 
pital, in tents, was ready to receive patients 
other than those requiring major surgery. 
Installation of the refrigeration machinery was 
not completed until 70 days after landing, and 
it took Syi months to set up the laundry 

Although this hospital proved to be much 
less mobile than had been hoped, we were able 

to send out a completely mobile unit of 100 
beds. The hospital was shipped by air to a base 
several hundred miles away and set up in a 
suitable location, where it served throughout 
the exercises. Under the able direction of Lt. 
Comdr. Warren E. Klein (MC) USN, this 
"Mobilette" accompanied a force of Marines on 

U. S. Naval Mobile Hospital No. 1 was moved 
to Bermuda in September 1940. There it served 

our forces for many months. 

It was demonstrated that mobility, as a qual- 
ity of military hospitals, existed in inverse 
proportion to the service it was prepared to 
give. The field hospital could be moved quickly 
because it did not have the heavy equipment 
that enabled the evacuation hospital to carry 
out definitive treatment for all classes of 
patients. A point to be remembered is that when 
a hospital stays in one place for a considerable 
time it loses mobility. Gradually, concrete 
foundations replace wooden ones, strong walls 



replace tent pins, machinery is put on per- 
manent bases, and everything tends to put 
down roots and grow fast. 

The lessons we learned were the subject of 
a report to the Bureau of Medicine and Surgery, 
helping to correct errors and deficiencies when 
planning later base and mobile hospitals. Much 
of the credit for these improvements belongs 
to Rear Admiral Kent C. Melhorn (MC) USN, 
one of our most forceful and clear-thinking 
medical officers. 

An amusing but irritating incident will illus- 
trate how easily hard-earned knowledge can 
disappear or be hidden. After my return to 
the United States I was discussing our experi- 

Lions a 

Advanced bases, like other operations of 
World War II, were on a scale never before 
imagined. The far-flung network of bases 
touched every climate, from that of Iceland 
to the Tropics. Some bases moved into areas 
formerly little known to man. As a security 
measure, code words were used to designate 
the bases when they were being assembled. Lion 
meant a unit designed to provide all necessary 
services, including medical and hospital, for 
an advanced base of 50,000 or more men. Cub 
meant a unit designed to serve a smaller 
advanced base. Sometimes a scion from a Lion 
served as a Cub. 

By the time the first Lion went overseas, the 
construction battalions had been inaugurated. 
It was intended that they would erect hospitals, 
but because the hospitals were part of a mili- 
tary force, combat requirements often took 
precedence over medical and hospital needs. 
When work of higher military priority took the 
Seabees away from construction work on the 
hospital, the medical officers and hospital corps- 
men took up the work and hurried it on to com- 
pletion. It was difficult for a physician, even 
when he became a medical officer, to conceive 
of anything more vital to a command than 
hospital service. This point of view drove them 
to strain, night and day, for completion of the 
hospitals in order that they might be able to 

ences with a medical officer who had \^ 
concerned with the Washington end of ^ 

*'You weren't the first to find out about thos^ 
deficiencies,'' he told me. *'We already 1^^^^ 
about some of them through reports of Mar 

"Then why wasn't I told about them? 
did we have to learn them all over again, w^^^ 
ing time, effort, and money?" 

'^Because those reports were confidential," ij^ 
replied. '*As long as I am responsible for then^ 
confidential reports remain locked in the safe 
Nobody sees them or knows what's in thc^ 
but me." 

d Cubs 

care for the sick and wounded. It also caused 
from time to time, considerable friction and 

Each mobile hospital presented its own prob- 
lems of arrangement, erection, and operation. 
These depended on location, terrain, the scum 
of supplies, the mission of the hospital, anc 
other variables. Because I was senior medica 
officer of Lion One, the Medical Department o: 
which later became U. S. Naval Base Hospita 
Number 6, that outfit is presented in detail. 

Lion One 

Advanced Base Unit, Lion No. 1, was estab- 
lished at Moff ett Field Naval Air Station, Calif, 
on 15 July 1942. The organization followed, 
in general, that of a medical department divi- 
sion afloat, with the various divisions included 
in the command retaining a considerable degree 
of independence. This allowed the head of eact 
department latitude in planning, all the plaa^ 
beirig coordinated by the division commander. 

All the officers except the senior medica. 
officer and the executive officer were naval Re- 
servists. It is fitting to record here a tribute to 
the work and the character of those Reservist 
physicians and dentists. Without complaint they 
sacrificed incomes, practices, and hospital posi- 
tions they had worked hard for years to win* 
Some were unable to keep up their insurance 



of their reduced incomes, and their 
farnili^^ had to give up their usual standards 

Most of the physicians had had little or no 
raining in the Navy's v^ay of doing things. 
Thev came full of desire to do their part and 

learn how to work in a world of unfamiliar 
customs and traditions. Many had been the 
leading practitioners in their home communi- 
ties and their clinical work was on the highest 
level. No sick men ever had more devoted and 
^killful care. The specialist units were of the 
greatest value. We had six associate professors 
from Stanford University Medical School who 
had worked together for years. They knew how 
to cooperate and made a wonderful team. Phy- 
sicians and dentists are commonly looked upon 
as individualists with little inclination to work 
together, but our men quickly fused into a 
well-rounded harmonious group. Their whole 
interest was concentrated on finding ways to 
make their special training and knowledge most 
valuable in the service of their country. 

As the years pass I realize more and more 
clearly how much the success of our enterprise 
was due to the physicians and dentists who 
came to us as Reserves. There is a strong 
tendency for personnel in the armed services 
to become hidebound and cloistered in their 
thinking. When war comes there is an infusion 
of new blood into the services which makes 
them aware that there is another world outside 
their circle. This comes often as a shock, but 
it is invaluable to the career people in the 

Lion One was established at Moffett Field, 
in the suburban area south of San Francisco. 
Materials had been assembled at the Advanced 
Base Supply Depot in Oakland, Calif. The men 
were housed in two-story wooden structures, 
relics of World War I, in such condition that 
they quickly became known as ^'Splinter City.'' 

The organization of the medical department 
Was along the following lines : 

1. Providing for sick call. 

2. Arranging w^ith the station dispensary for 
^re of our sick and their transportation to 
the Mare Island Hospital. 

3. Examining health records, checking iden- 
tification tags, giving necessary inoculations. 

4. Doing complete physical examinations of^ 
all personnel. 

5. Establishing a dental clinic, preparing a 
dental record, and beginning dental treatment 
for those requiring it. 

6. Making bag inspections. Each person was 
required to have all the necessary articles of 
clothing, including the special articles needed 
for expeditionary duty. Hammocks and lashings 
were required for all enlisted men. 

7. Interviewing all officers, to learn their 
professional, musical, dramatic, athletic, teach- 
ing, or other special abilities. Planning for 
recreation and amusement was considered 

8. Lecturing to officers on the mission of 
Lion One, their special obligations, naval cour- 
tesies, administration, records, morale, and 
policies, and lecturing to chief petty officers on 
their duties with regard to discipline and their 
obligation to look out for the welfare of the 
men under them. 

Great attention was paid to hardening the 
men in preparation for the strenuous duties 
that were anticipated. There were daily periods 
of physical exercise, drills, and competitive 
athletics. Minimum standards of physical ac- 
complishments were set up for men and for 
officers of all ages. Cross-country hikes were 
made at least once a week. Swimming instruc- 
tion was given to all who needed it. Teams from 
the various divisions competed at least weekly 
over the obstacle course. Thanks to the excellent 
leadership of Lt. H. H. Martin, an orthopedic 
specialist of Riverside, Calif., the Hospital 
Corps usually won the weekly contest. 

The stay at Moffett Field gave us time for 
careful physical and mental examination of 
men and officers. It was possible to eliminate 
many who would have broken down under 
strain and have become a source of danger to 
their associates. The Navy shoes and the ..issue 
of cotton socks were found to be totally unsuit- 
able for wear in the field. Eventually field shoes 
like those used for the Marines, and woolen 
socks of good quality were provided. 

Classes in first aid for all hands were taught 
by an instructor from the Red Cross, and 
physicians with years of experience in han- 
dling surgical emergencies were surprised to 



= 1 ION=QNE = 


M«dic«< Corps 

Mediol Corps 








c . I 




Office RS 




Figure 145. — Lion One medical department organization. 

find how much useful information they gained 
from this instruction. All medical and dental 
officers were required to qualify as instructors 
in first aid. Courses in gas warfare, small arms, 
and antiaircraft were also made compulsory 
for all hands. 

Most of the men of the Hospital Corps were 
newly recruited and had little knowledge of 
hospital work or care of the sick. Training 
courses for them were organized in the civilian 
hospitals of cities near by. The authorities of 
these hospitals were quick to realize the urgent 
need for instruction of these green men, and 
gave admirable cooperation. 

Instruction of the hospital corpsmen, who 
were being trained for work in the operating 
room, included practice on the sewing machine. 
The wife of one of our medical officers under- 
took this teaching. Many special articles such 
as binders, glove packets, and special dressings 
were made in the surgical workroom. 

Our planning was based on the information 
that the medical facilities at our destination 
would consist of three 200-bed hospitals and 

about 20 dispensaries. The medical officers an., 
hospital corpsmen were divided into apprt- 
priate groups to provide service for these ac- 
tivities. Teams were organized and special!: 
trained for rapid handling of shock, transfr 
sions, burns, and other combat injuries. 

Based on the limited information that 
had about our future location and duties, ft 
plan of organization shown in figure 145 
adopted. Each head of a section was told thaj 
he was expected to exercise as complete contr i 
as possible over the personnel and activifc 
under him. This recognized the probabili' 
that the various parts of the organization wou 
be so widely scattered that centralized contr 
would be impracticable. 

Commissioning ceremonies for Lion Or 
were held on 15 July 1942. In December order 
were received to divide the medical staff ii^' 
three task forces, each containing all the elr 
ments necessary for a 200-bed hospital. The? 
groups sailed separately, beginning in Januar 
1943, the last one reaching our base at Espirf 
Santo, New Hebrides Islands, on 24 April 



Figure 146. — Anatomy of a quonset hut; laying the frame. 

Soon after our arrival I was fortunately able 
*n visit Naval Base Hospital No. 2 at Efate, 
. hich was commanded by Captain John Porter 
(MC) USN. This hospital had been established 
^or several months and had already met and 

)lved most of the problems that were to con- 

front us. Thanks to the lessons learned from 
this well-planned and smooth-running institu- 
tion, we were saved many of the mistakes we 
might otherwise have made. 

On 9 April a dispensary and wards were 
opened in tents, and 10 days later they were 

Figure 147. — Anatomy of a quonset hut; erecting the ribs. 



Figure 148. — Hospital completed. 

transferred to quonset huts. This type of 
building housed most of our wards and depart- 
ments. It was soon found that placing several 
of the 20- by 36-foot huts end to end made a 
good working unit. Longer units were tried with 
increasing satisfaction, the longest one, 340 
feet, proving to be best of all. Our hospital site 
was in a coconut grove. The rows of trees were 
25 feet apart and the 20-foot buildings fitted 

snugly between the rows. Buildings at 
angles, with a frame structure to join til 
provided very useful units. Quonset huts 
found to be extremely useful for nearls 
hospital needs as well as for quarters. 

The work of erecting the buildings (figs, 
and 147) was under the direction of the 444 
Construction Battalion, which deserves grd 
credit for excellent planning and for carryif 

Figure 149. — Hospital completed in a coconut grove. 




, work under most difficult conditions, 
hundred and fifteen of our men worked 
^^^r * their direction. As hospitals have a 
^ h ^r low priority, the Seabees were fre- 
tly pulled off the job, but our men rapidly 
^^^^me proficient in the work and the buildings 
up rapidly. Officers and men worked along- 
each other, in the rain and mud, with a 

^ boy-scout spirit. It was found advisable 
t build first the access roads ; second, the quar- 
ters for the enlisted men ; third, hospital offices ; 
fourth, outpatient clinics ; fifth, hospital wards 
and mess hall; and sixth, officers' quarters 
^ i^rs. 148, 149, 150, and 151). 

It was soon evident that the time of the 
Senior Medical Officer would be about equally 
divided between (1) sanitation, (2) dispen- 
saries, (3) construction, and (4) receiving and 
evacuating patients. Competent medical officers 
were therefore detailed to superintend each of 
these activities. 

Sanitation was early recognized as a vital 
factor for survival in the Tropics. We were 
fortunate in having a man trained in public 
health work. Commander James A. Beauchemin 
(MC) USNR, who had a special gift for induc- 
ing people to comply willingly with his recom- 

mendations. Practically anything one may do 
for advancement of the public health inter- 
feres with the prejudices, the profits, or the 
comfortable routine of someone. That someone 
is often powerful enough to offer obstinate 
resistance. For this reason, salesmanship is 
often more important to the sanitarian than 
scientific knowledge. 

Sanitation had received little attention before 
our arrival. It was the rainy season; as much 
as 7 inches of rain fell in a day. There were 
no roads and the soil was deep and rich. Men, 
machines, and supplies were dumped ashore, 
frequently at night because of enemy pursuit. 
Ruts made by machines quickly filled with 
water and became the breeding places for mil- 
lions of mosquitoes. Food wastes were dumped 
promiscuously and there was widespread pol- 
lution by men who either knew no better or 
could not be bothered. Dysenteries and mos- 
quito-borne diseases took such a heavy toll of 
personnel that it was difficult to maintain 
watches or to get work done. 

Many large industrial areas were soon de- 
veloped. It was necessary to have wide disper- 
sion for military reasons. Twenty-seven sepa- 
rate sickbays and dispensaries with accommo- 





: J 

Figure 151. — Officers* quarters. 

dations for more than a thousand men were 
placed in operation on a 24-hour basis. The 
plan was to send those who were disabled for 
more than 24 hours to the main hospital. 

Patients came to us by ship and by airplane. 
Hospital ships brought hundreds of sick men 
at a time while other ships received large num- 
bers for evacuation to the rear. This reception 
and evacuation of patients required careful 
planning to make it work smoothly, requiring 
the entire time of a number of officers and men. 
On 12 July 1943 authority was received to 
expand to 1,000 beds and on 25 August the 
hospital was designated as Naval Base Hospital 
No. 6. 

The following is a summary of the problems 
and solutions: 

1. Sanitation and public health are of the 
greatest importance in the field and also at 
a newly established base. Military planners may 
forget this vital point, even though many expe- 
ditions have failed because of it, unless the 
medical officer brings it to their attention. 
This must be done with tact, because military 
leaders resent the idea that a physician can 
tell them facts about their own specialty. Men 
skilled in sanitation should be with the first 
troops to land in a new area. 

2. In hospitals on Guadalcanal, only 3 per- 
cent of the patients were battle casualties, while 
97 percent had malaria, dengue, or dysentery. 
This ratio should be considered as normal in 
base hospital planning for the Tropics. 

3. Before embarking, the men should be 
carefully screened in order to eliminate those 
physically, mentally, and temperamentally 

4. In any military outfit, the combat require- 
ments always take precedence over medical 
and hospital needs. 

5. Last-in-first-out stowage in ships or other 
means of transportation is essential. An officer 
should be assigned to keep close watch with 
the loading officer and should know exactly 
what material is stowed in each compartment 
of the hold. He should be alert to detect any 
unauthorized changes or removals. 

6. Spare parts and blueprints for all ma- 
chines are essential. If possible, the machines 
should be set up and operated before they are 

7. The contents of cases will not always agree 
with the labels unless each package is opened 
and inventoried before being shipped. Errors, 
pilfering, and substitution will occur. 



g Avoid tents for quarters and for hospital 
,e whenever possible. 

Hospital bed capacity must always be very 
istic Usually a large number of patients will 
^^brought to the hospital before it is ready to 
^ n Often a number greater than the normal 
b^d capacity will be sent in, without notice, 
at any hour. 

10. It is essential that every officer and petty 
,tficer know the men under him intimately. He 
•>^ust be familiar with their attitudes, qualifi- 
cations, athletic and musical abilities, matri- 
Jnonial difficulties, and personal, legal, and 
financial problems. 

11. Minor ills, such as sunburn, sore feet, 
and influenza, can disable large numbers of 
men for long periods. The best treatment is 

12. The officers and men in the Medical De- 
partment can be depended on to show great 
versatility and ingenuity in meeting emergen- 
cies. They will perform with success and 
enthusiasm duties far removed from their usual 

13. Planning: The officer in charge of con- 
structing the hospital should visit the site in 
advance of the arrival of the materials, and 
plan the layout to fit the terrain. He should pay 
special attention to the brush or trees to be 
cleared, areas of insect breeding, water and 
power supply, roads, and means for disposal 
of wastes. Providing for recreation and enter- 
tainment requires careful consideration; these 
are important morale builders. 

14. Careful packing and marking of equip- 
ment are essential. Blueprints of each machine 

U. S. Naval Base 

The somewhat different problems of com- 
pletely nonmobile base hospitals and the ways 
in which they were solved under war conditions 
are best illustrated by an account of the opera- 
tions from 1 March to 30 September 1944 of 
U. S. Naval Base Hospital No. 12. This was one 
of three hospitals cited for the Navy Unit Com- 
mendation, the other two having been awarded 
to the U. S. Naval Hospital Pearl Harbor 

should be in the same crate with the machine. 
Labels and marking should be used which will 
not smear in handling or come off when wet. 
Whenever possible, boxes should weigh not 
more than 250 pounds; if heavier, they will 
get rough handling. 

15. The power plant requires careful study 
of the prospective needs for heating, lighting, 
water pumping, cooking, kitchen machines, 
refrigeration, sterilizers, and laundry. Consid- 
eration should be given to the type of materi- 
als for construction, methods of transmission of 
power, availability of various types of fuel, 
spare parts, and maintenance. Several types of 
reliable mobile generators are available. 

16. Housing : Tents are the most mobile type 
of shelter, but the fire hazard is great, they 
last only 4 to 6 months, and are the most costly. 
Prefabricated buildings are more convenient 
and comfortable, and permit giving better 
medical and surgical care, but require more 
room in shipping. 

17. Food: Good cooks and palatable food 
are important for morale, as well as in the care 
of the sick. 

18. Motor transport: Jeeps, passenger cars, 
ambulances, several sizes of trucks including 
at least one with a crane, motorcycles, plenty 
of spare parts, tires, air compressors, lubri- 
cants, and full equipment for repairs will be 

19. Periods of strenuous activity will be 
followed by dreary days of sitting about with 
nothing to do. Avoid loss of morale by planning 
athletics and musical and dramatic occasions. 
You will find plenty of talent in any large 

Hospital No. 12 

and to the U. S. Naval Mobile Hospital No. 2 
for their heroic services on 7 December 1941. 

In preparation for handling casualties from 
the proposed cross-channel invasion, the Navy 
on 28 February 1944 took over the old Royal 
Victoria Hospital at Netley, near Southamp- 
ton, England (fig. 152). When the Medical 
Officer in Command, Captain C. J. BrownS 

iNow Rear Admiral (MC) USN. 



Figure 152.— U. S. Naval Base Hospital No. 12, Netley, Hants, England. 

arrived with his Executive Officer, Captain J. 
W. Miller, and a few advance units of person- 
nel, it was obvious that tremendous effort 
would be required to put the installation into 
shape for efficient functioning in the short 
space of time remaining before D-day. 

Most of the buildings had been constructed 
about the middle of the nineteenth century and 
were in a poor state of upkeep and repair. The 
roof leaked, hundreds of windowpanes were 
broken, extensive cleaning and painting were 
required, the deck was in bad shape, lighting 
was very unsatisfactory, wards and rooms were 
poorly heated if at all, the supply of gas and 
hot water was inadequate, galley equipment 
and refrigeration were obsolete and insufficient, 
linen rooms and storerooms were in chaotic 
condition, there were no wards suitable for 
neuropsychiatric care, and most of the furni- 
ture and equipment that was not completely 
unserviceable, required extensive repair. 

In order to be ready to receive large numbers 
of casualties by the rapidly approaching dead- 
line date, the aid of a construction battalion 
was obtained, but because of military demands 
on the time of these Seabees much of the clean- 
ing, painting, repair work, and installations 
had to be completed by hospital personnel. To 
remove unserviceable furniture, equipment, and 
debris from the buildings and grounds, carry 

out the most essential cleaning, and sterilize 
mattresses, pillows, and blankets, required 
2,900 man days. 

Intensive effort was exerted to obtain neces- 
sary equipment and supplies from every avail- 
able British and American source. The bulk of 
equipment for a 1,000-bed base hospital was 
gathered from various U. S. Army depots. 
Among special items installed were 150 space 
heaters with 16 fuel tanks, 60 lavatories, 32 
showers, 3,000 feet of shelving, 12,000 square 
feet of lockers and partitions, galley equip- 
ment with cold rooms and refrigerators, elec- 
tric transformers and wiring, and a roent- 
genographic machine. 

In addition to the clean-up and equipping 
program, organization and training of the hos- 
pital personnel was rapidly carried out during 
the weeks prior to D-day. The medical officers 
were given intensive courses in first aid, gas 
defense, treatment of shock and burns, and the 
handling of casualties on a large scale. Plai^-' 
were perfected for the sorting of casualties anc 
their transportation within the hospital, witt 
particular attention to the handling of shock 
and burn cases. To eliminate confusion wher. 
large numbers of patients were received at one 
time, a method of current empty-bed check "^'^ 
adopted under which triage was conducted 
person by the Chiefs of Surgery, Medicine, anc 




Each Chief of Service was 
s ahle to assume immediate responsibility 

f a group of incoming casualties, was cur- 

.^iitly familiar with the bed situation, and 
could foresee and plan the work of his depart- 

In preparation for expected sudden demands, 

^^pplies of penicillin, plasma, and blood were 
located and a central surgical supply room was 
organized. In the Orthopedic Department, 7,000 
plaster bandages were prepared. Resuscitation 
rooms, burn wards, and locked wards were pro- 
vided. The three steam hydraulic elevators were 
repaired and a system of handling baggage and 
valuables inaugurated, permitting rapid collec- 
tion and equally rapid evacuation. Operating 
suites were prepared so that 6 operations could 
be conducted simultaneously, and operating 
teams were organized, with hospital corpsmen 
trained in operating room technique and dental 
officers trained to assist in anesthetic proce- 

Because the hospital was within 12 minutes 

flying time from enemy airfields and was located 
adjacent to important military targets, organ- 
ization for air-raid defense was required. 
Personnel were indoctrinated in the use of 
underground shelters, gas cleansing centers, 
lire fighting apparatus, and rescue equipment. 
Frequent casualty-handling drills were carried 
out. Medical stores and personnel were dis- 
persed in shipboard fashion. Look-out stations 
were manned 24 hours a day. Frequent night 
alerts, requiring all hands to man emergency 
stations, with the ever-present threat to pa- 
tients and staff, were very disturbing, partic- 
ularly after numerous robot bombs began 
landing in the vicinity and shaking the build- 
ings with their explosions. 

During March, April, and May, even while 
the installation and organization were in the 
process of being brought up to an operating 
condition conforming to Navy Standards, 1,554 
inpatients were treated. On D-day, as many 
beds as possible were cleared for reception of 
battle casualties, 212 patients being evacuated 
by hospital train and 56 others sent to duty. 
Casualties then began arriving by ambulance 
from hospital carriers and LST's, usually in 
large groups. Daily admissions of 100 to 200 
were common and on several occasions 200 to 
300 were admitted in the course of a few 
hours. Such mass admissions were an all-hands 
procedure. On 11 June there were 357 admis- 
sions, on 6 September 420, and on 22 September 
283 convalescent patients were evacuated while 
409 new casualties were being admitted. 

During June, July, August, and September, 
8,076 patients, including 4,226 battle casualties, 
exclusive of neuropsychiatric cases, were ad- 
mitted. Despite the fact that, starting with an 
installation in an extreme state of disrepair, the 
hospital had been prepared to receive them in 
the short space of 3 months, and that the per- 
sonnel labored under every conceivable handi- 
cap of material shortages, overwork, and sub- 
jection to air-raid alerts, the results obtained 
were outstanding. The mortality rate among 
the wounded in battle was only 0.26 percent and 
the surgical mortality, 0.70 percent. To quote 
from the Navy Unit Commendation so justly 
awarded, "—the brilliant results obtained in 
the professional care of great numljers of battle 
casualties, constitute an exceptional and dis- 
tinctive record of achievement, in keeping with 
the highest traditions of the United States 
Naval Service." 

Chapter IV 

Medical Procurement and Supply 

Kent C. Melhorn, Rear Admiral (MC) USN (Reiired) 
Lewis G. Jordan, Capta'm (MC) USN 
William L Engelman, Capiain (MC) USN 

At the beginning of the war the functional 
organization of the Bureau of Medicine and 
Surgery (BuMed) did not concentrate control 
of materiel in a single office. This resulted in 
considerable overlapping and duplication of 
effort. There were conflicts of authority between 
the Planning and Finance Divisions of the 
Bureau and the Naval Medical Supply Depot, 
Brooklyn, related to materiel planning, the 
determination of requirements, and the pro- 
curement, inspection, and distribution of ma- 
teriel. The Surgeon General had a management 
survey made by a firm of business consultants. 
As a result on 10 November 1943 the Materiel 
Division, BuMed, was established in Brooklyn, 
as an organizational entity housed in but ad- 
ministratively separate from the depot. This 
located the Division in the immediate vicinity 
of the New York offices of all the important 
manufacturers with which it did business — a 
most advantageous arrangement. A Division 
branch office was maintained in Washington 
for liaison with the Bureau. 

Before 10 November 1943, a special depart- 
ment of the Brooklyn Medical Supply Depot 
had discharged various responsibilities for the 
Bureau of Medicine and Surgery. These were 
transferred to the new Materiel Division, 
which was given a wider range of authority 
than its depot predecessor. In addition, author- 
ity over certain areas of responsibility previous- 
ly discharged by the BuMed Planning and 
Fiscal Divisions was transferred to the Mate- 
riel Division. Therefore, when in this article 
the Materiel Division is given credit for actions 
taken before its creation it is done to simplify 
the narrative. 

The Materiel Division was given plenary au- 
thority over the Medical Supply System, in- 
cluding materiel planning, requirements de- 
termination, procurement (less purchasing 
done by NPO, New York), inspection, inven- 
tory control, and operational and management 
control of Naval Medical Supply Depots and 
Naval Medical Supply Storehouses (MSS's) in 
the Continental United States. Operational 
control of overseas MSS's was exercised by 
the Area Command, but the Materiel Division 
exercised management and technical control. 

At the end of the war the Materiel Division 
had a staff of about 150 officers, enlisted men, 
and civilian employees and occupied 25,000 
square feet of office and laboratory space, in 
comparison with the half dozen people in the 
Brooklyn depot who handled the very small 
materiel operation before the war. Procure- 
ment volume rose dollarwise from approxi- 
mately $1,000,000 per annum in fiscal year 
1940 to a height of $120,000,000 per annum 
during fiscal year 1944. 

In 1941 medical stores were distributed from 
three Naval Medical Supply Depots, one at 
Brooklyn, N. Y. ; another at Mare Island, Calif. ; 
and a third at Canacoa, P. I. The latter was 
lost when the Japanese invaded the Philip- 

At the end of hostilities there were 2 large 
continental Naval Medical Supply Depots, with 
numerous satellites (fig. 153). The depot at 
Brooklyn together with its Annex at Edge- 
water, N. J., had over 1 million square feet 
of storage area. Brooklyn also controlled the 
activities of a supporting half million square 
foot Medical Stores Section in the NSD, Me- 



chanicsburg", Pa., and satellite storeho 
averaging 40,000 square feet each at New-n. 
R. I. ; Norfolk, Va. ; Charleston, S. C. ; and^ 
Orleans, La. These made issues to minors 
medical activities ashore and afloat. 

The depot at Mare Island had been repla^^ 
by a new depot at Oakland, Calif., ^j^r[^^ 
capacity of over 600,000 square feet. The Qa 
land Depot also controlled the activities 
supporting Medical Stores Sections in 
NSD's at Clearfield, Utah, and Spokane, Wa. 
with a combined total of several huiiii 
thousand additional square feet, and satb 
storehouses at San Diego and San Ph 
Calif., and Seattle, Wash. Thus, this contir 
tal complex had a combined area of appi 
mately 3,200,000 square feet of space, an-; 
its peak stored up to 40,000 tons of mate 
worth over $100,000,000. The techniques 
continental supply distribution remained rek 
tively unchanged. The main difference wash 
the amounts involved. 

Early in the war it became evident tk 
under the conditions then existing the ove: 
seas forces ashore and afloat and the 
Marine Force could not be supported satisfai 
torily from continental depots. Starting i: 
1942 relatively small naval medical depoi 
were established at Pearl Harbor, T. H., an. 
at Balboa, C. Z. For the Atlantic Area medica 
supply storehouses (MSS's) were establishe; 
at San Juan, P. R. ; Recife, Brazil ; Casablana 
Morocco; Londonderry, Ireland; and finally a 
Exeter, England. All of these served usefuE 
throughout the war. The concept of MSS 
located at strategic ports ideally fitted the pa: 
tern of naval operations in the Atlantic. Flet 
employment was mainly for convoy escort ar. 
for air and surface antisubmarine and surf 
ace raider patrol measures. In addition, tb 
MSS at Exeter played an important role 
the Normandy invasion. 

During early 1942 w^hen the Japanese ^ve^ 
still sweeping forw^ard in the Pacific, MSb 
were established at various places in Austrafc 
New Zealand, Noumea, and Espiritu Santo, ar. 
proved invaluable. Initially all those MSS 
were supplied by automatic shipments. Subse- 
quently replenishment was by requisition- 
After the Battle of Midway the offensive 


the Pacific gradually passed to our side and 
the Naval and Marine Corps forces which at- 
tacked and conquered the Solomons, New Brit- 
ain, and New Guinea were mounted out of 
these facilities. 

With the perimeter in the South and South- 
west Pacific firmly held, a new phase began to 
develop. The MSS's in Australia, New Zea- 
land, Noumea, and Espiritu, and the Supply 
Depot at Pearl Harbor, progressively lost value 
as the war moved north and west. Some of 
these facilities were dismantled and moved 
forward to Guadalcanal and Manus, where 
they served usefully for many months until 
they, too, got off the direct line of communi- 

Geography and the augmented might of the 
fleet produced a new type of warfare in the 
Pacific. Development of new supply techniques 
and the increasing number of cargo vessels 
available made it possible for the fleet to re- 
main underway for extended periods in distant 
forward areas. It ranged swiftly into enemy 
home waters for strikes at Japanese bases and 
had the endurance to constantly contain the 
Japanese Fleet within the range of its shore- 
based air support. This ascendency of the 
Pacific Fleet in w^hat were formerly enemy seas 
made possible the mounting of major amphib- 
ious forces which were escorted to and sup- 
ported at the distant assault objectives with 
surface and air protection. Their materiel re- 
quirements were provided by a magic ^rpet 
composed of hundreds of cargo ships on a 
conveyer belt schedule. 

The vastly increased quantities of materiel 
required by constantly larger and more fre- 
quent assault operations made necessary the 
return of responsibility for primary supply 
support to the continental medical supply 
depots. Pacific MSS's were now off the routes 
of communications between the Continental 
United States and the zone of combat opera- 
tions. It was not until we got to Guam that a 
land mass large enough to use as a major 
staging area was secured. The last MSS was 
erected in Guam. Its mission was mainly local 
supply, rehabilitation of MarDivs, and the 
storage of emergency stocks which could be 
called for when needed. It was more efficient 


and economical of materiel and shipping to 

supply from the United States than to rou- 
tinely ship to Guam, off-load, and later reship 
to more forward areas. Thus, the place in 
medical supply of the Pacific MSS's was taken 
over by floating supply and block shipments to 
the assault and garrison forces. Medical supply 
afloat at the end of the war was furnished 
from 28 AK's and 8 barges. Block loads were 
prepackaged units of medical and dental ma- 
teriel delivered at destination by cargo ships. 
When an objective was secured, the occupa- 
tion forces at the new base were supported for 
a short time by automatic shipments for cur- 
rent maintenance and accumulation of its pre- 
scribed stock levels, after which they went on 
a requisition basis. 

As far as the public could see, the most vis- 
ible drama of naval medical supply took place 
in the Pacific with the Service Force Pacific, 
the Fleet Marine Force Service Regiments 
playing the most prominent roles. We must, 
however, keep in mind that behind the adver- 
tised players in any show is a supporting cast 
and the director and producer, without whom 
nothing can start or go forward to successful 
accomplishment ; they are the base of the pyra- 
mid. The Materiel Division in Brooklyn and the 
Medical Supply Depots and their controlled 
Medical Stores Sections supplied the muscle 
which was flexed by the Service Force and 
Service Regiments and it provided the sinews 
which supported the less publicized but very 
important and equally eflTicient medical supply 
operations in the Atlantic, Africa, Europe, and 
continental United States. 

The relations between the Bureau's Materiel 
Division on the one hand and the Medical 
Sections of the planning and operational staffs 
of the Theater or Area Commanders on the 
other were intimate and cordial, and the tech- 
niques of coordination and integration of their 
respective thinking and actions makes a fasci- 
nating story. 

Bureau planning stemmed from directives 
from higher authority. The Joint Chiefs of 
Staff (JCS) developed broad, sequentially pro- 
gressive, and time-phased strategic plans. 
These were passed to the Departments for 
preparation of subsidiary tactical plans and 


preparation of estimates of the logistic require- 
ments to implement them. The Chief of Naval 
Operations (CNO) developed the Navy plans 
and with the assistance of the Bureaus and the 
area operational commanders determined its 
total requirements for accomplishment of the 
role assigned the Navy. The several Depart- 
Inental requirements for personnel, facilities, 
and materiel v^ere consolidated by the JCS and 
forwarded to the War Production Board and 
the War Manpower Commission. These agen- 
cies, which had the authority to divide the 
national assets between the civilian and mili- 
tary economies and the demands of our Allies 
for Lend Lease, compared the over-all esti- 
mate of requirements with the national pro- 
ductive capacity of industry, the supply of 
basic materials, and the available manpower 
resources, and determined if it was feasible 
to provide the military with what was asked. 
If the demand could be satisfied, implementa- 
tion of the supporting programs went forward. 
If the demands could not be satisfied, the scope 
of planning was reduced to what was support- 
able, or the operations were postponed until 
the requirements could be accumulated. 

This over-all feasibility test had the value 
of precisely indicating the bottlenecks and 
zones of scarcity which required corrective 
action. Logistic materiel deficits were some- 
times compensable by assigning priorities for 
scarce materials, productive capacity, and in- 
dustrial manpower among competitive pro- 
grams, by enforcing use of alternate materials 
and fringe production by the less essential pro- 
grams, and by cancelling programs for desir- 
able but not really essential items. 

Thus, deciding upon a date for the '*Kick- 
off'' of major combat operations was intimately 
related to a reasonable expectancy that indus- 
try could deliver enough of all the essential 
material to mount out and maintain the opera- 
tion, and the acceptance as a calculated risk of 
unforseeable delivery failures. 

When the scope and timing of operations had 
been set, it was up to the Materiel Division 
to buy what was needed and to get the goods 
into its depots in time to meet the mounting 
out shipping dates prescribed by higher author- 
ity and the forces in the field. This required 



eifective organization, superior administrative 
and operational direction, imagination, cour. 
age, initiative, sound judgment, and a tremen. 
dous amount of hard, exacting work. 

The magnitude of the problem that had to 
be met, and was met, was defined at the begin, 
ning of this article but will be summarized 
here to emphasize why personnel who accom. 
plished what was done had reason to be proud 
of the results achieved. This was a sixty-fold 
(6,000 percent) increase in the scope of the 
medical supply operation within a period of 
less than 24 months, in a highly competitive 
environment. Manpower, materials, productive 
capacity, all types of equipment, and facilities 
construction were in limited supply and could 
only be procured by unremitting, intelligent, 
and strenuous effort. 

That this was done is attested by the fact 
that very few significant Navy medical supply 
failures occurred during the war. If anyone 
did not get the exact item he asked for it was 
due to the following policy : In order to more 
effectively use available manufacturing capac- 
ity and to conserve scarce materials and 
skilled manpower, government and industry 
agreed to limit the variety of similar purpose 
items produced. This resulted in greater pro- 
duction of the most needed items. If it was 
manufactured it was supplied to the Navy con- 
sumer. That the Naval Medical Supply Depots 
fulfilled their portion of the mission can be 
supported by the fact that the Oakland depot 
received an plus" rating from the War 
Manpower Commission for efficient organiza- 
tion and utilization of personnel. This was as 
high a rating as was awarded to any Navy 
Supply Depot operation during the period of 
the war, and possibly the highest. Brooklyn 
was but a step behind. 

The medical elements of Area or Theater 
and Fleet Command Staffs and the overseas 
MSS's effectively contributed to the success of 
medical supply. They evolved efficient ne^v 
techniques in the planning and implementation 
of getting sufficient quantities of the rigW 
items to the right places when they were 
needed. They kept the Bureau, the Materiel Di- 
vision, and the depots constantly advised o: 
changing conditions and requirements in the 




g under their respective cognizances. 

While the Pacific areas presented more novel 
edical material problems to the Navy than 
her regions, certain of them were common 

to all. Some of the more significant solutions 
arrived at, which have already been summarily 
referred to, will be outlined below in detail 
by categories of programs : 

Advanced Base Program 

The establishment of Advanced Base Units 
was first considered early in 1941 in connec- 
tion with Lend-Lease and the development of 
bases in the Western Hemisphere. About April 
1941, the Brooklyn Medical Supply Depot re- 
ceived a directive to purchase and assemble 
supplies and equipment for two 600-bed hos- 
pitals and two 200-bed hospitals, which were 
to become the medical components of destroyer 
and seaplane bases. At this critical period, 
cargo ships were being sunk at an alarming 
rate and shipping space was at a premium. In 
preparing allowance lists for such units, the 
shipping weight and cube of the material and 
equipment had to be held at a minimum. Sup- 
plies were provided for a 6-month period and 
the total allowance was divided into three and 
two echelons respectively for the destroyer and 
seaplane bases. Some equipment was dupli- 
cated and shipped on different vessels in the 
event that one was lost. Such a division of 
the material also allowed the splitting off of 
one or more parts to form two or three hos- 
pitals of smaller size if the situation required 
dispersion of facilities. The allowance lists for 
these main bases included a number of small 
satellite dispensaries to be set up within the 
base as sick call and aid stations. The Medical 
Supply Depots furnished all medical supplies 
and equipment for the medical components. 
BuDocks supplied housing, utilities, transpor- 
tation, construction, and maintenance facili- 
ties, while BuSandA furnished office supplies 
and equipment and consumables. 

Late in 1941, destroyer bases became known 
as LIONS and the seaplane bases as CUBS. 
By this time another component, the ACORN 
Was added to the list of Advanced Base Units. 
The ACORNS were originated to provide 
shorebased aircraft groups in amphibious 
forces and advance bases, with necessary sup- 
port and services upon landing in combat 

zones. They required a high degree of mobility. 
The medical component of an ACORN pro- 
vided a 100-bed mobile dispensary in specially 
packed Field Medical Units and was divided 
into two echelons. Upon landing, the unit was 
housed in tents, which were replaced by huts 
when the base was consolidated. 

In the procurement of material for 
ACORNS, considerable difficulty was experi- 
enced in obtaining large quantities of special 
cases in which to pack the Field Medical Units. 
In addition, the standard hospital furniture as 
purchased under existing specifications did not 
lend itself to export shipping because of the 
large weight and cube and variety of shapes 
of the packing cases. An extensive revision of 
specifications and the redesigning of many 
items was needed, so that they could be shipped 
in a ''knocked down'' form. In addition, net 
items of equipment had to be provided to meet 
totally new or unanticipated medical problems 
in the field. 

Upon the outbreak of war, the material and 
equipment assembled for the original bases 
were diverted from the Lend-Lease program 
and shipped to combat zones. Additional 
LIONS, CUBS, and ACORNS were scheduled 
and assembled during the first half of 1942. 
By August 1942 schedules for each type of 
advanced base units had been promulgated, 
with assembly points and loading dates desig- 
nated. At that time the assembly points in- 
cluded Oakland-Hueneme, Calif., Norfolk, Va. ; 
Davisville, R. I.; and New Orleans-Gulfport, 

The readiness date for each component was 
set at 6 weeks prior to the scheduled loading 
dates. In accordance with the CNO schedule, 
the Naval Medical Supply Depots assembled 
the necessary supplies and equipment for the 
scheduled units and were, with few exceptions, 
able to meet readiness dates. In addition, dur- 



ing the latter part of 1942, the Brooklyn Medi- 
cal Supply Depot set up allowance lists for 
100-, 50-, 25-, and 10-bed continental and extra- 
continental dispensaries, Carrier Aircraft 
Service Units (CASU's), construction bat- 
talions, and 10-bed Mobile PT Bases, the latter 
specially packed similar to the ACORN. At 
this time, the depot established a schedule for 
Advanced Base Components in advance of 
CNO requirements, because continual demands 
were being made for Advanced Base Com- 
ponents over and above the CNO schedule. The 
procurement program for material and equip- 
ment was expanded to meet the requirements 
of the newly constructed Naval Supply Depots 
at Mechanicsburg and Clearfield for assembly 
and processing of the Advanced Base Com- 
ponents. This system enabled BuMed to ship 
all components to the tidewater assembly points 
intact, well in advance of the readiness dates. 

By March 1943 it had become apparent that 
LIONS, CUBS, and ACORNS were too large 
and included many components that were not 
required in all theaters of the war, while some 
facilities that were required for certain opera- 
tions were omitted. To correct this, the LIONS, 
CUBS, ACORNS, and PT bases were subdi- 
vided into individual functional components 
and letters of the alphabet were assigned to 
each group of components, with numeral sub- 
groups for the various units within the group. 
The Medical and Dental components were des- 
ignated as *'G'' components. 

On 15 March 1943 CNO issued the first edi- 
.tion of the catalogue of advanced base func- 
tional components, from which area com- 
manders could choose the necessary functional 
components to comprise the LION, CUB, 
ACORN, CASU, or PT bases required for the 
specific task at hand. During the late spring 
and early summer of 1943, preparations were 
made to have all Bureaus assemble material 
for individual components at inland depots, so 
that intact shipments could be made to loading 
ports. On 4 August 1943, the CNO issued the 
original schedule of individual components, and 
soon thereafter instituted Advanced Base Sec- 
tions at Naval Supply Depots to supervise, pro- 
cess, and report on material for all scheduled 
Advanced Base Components. 

Since BuMed had a well-established advance 
base section already functioning in the inlau^j 
depots, it was requested to continue process, 
ing and assembling the BuMed material 
the Advance Base Section of CNO could organ, 
ize and establish similar facilities for the other 
Bureaus. On 1 September BuMed had set up 
a serial list of components 1 to 10, iu. 
elusive — in accordance with CNO schedule of 
4 August. Other '*G" components were added 
later. The material and equipment were ac- 
cumulated in the depots well in advance of the 
availability date and marked with the assigned 
serial number. The serial numbers of the avail, 
ability schedule were revised with each sub. 
sequent monthly revision. In October 1943 a 
BuMed Scheduling Officer was appointed at 
Washington and at the Naval Medical Supply 
Depot, Brooklyn, N. Y. The former acted as 
BuMed liaison officer with the other Advance 
Base Sections at Washington, and the latter re- 
leased and controlled material and shipments 
of all components from Brooklyn. During 
November 1943 the Advanced Base Program of 
the Bureau was made the responsibility of the 
newly created Materiel Division. 

Dental coverage was provided by G-13 to 
G-16 inclusive. Under ideal conditions one den- 
tal officer was needed for every 750 men. Due 
to lack of personnel, one dental officer fre- 
quently had 1,500 to 2,000 men to care for. 
These small one-man dental clinics were not 
economical ; consequently, when the size of the 
base justified, dental clinics were tailored to 
size and ordered in. 

Preventive medicine units. In malarious 
areas a G-17 unit was provided. These malaria 
control components had ample supplies, equip- 
ment, and well-trained entomologists. During 
the establishment of new bases and until sani- 
tation had been brought up to standard, a G-18 
epidemiology component should have been pro- 
vided. These components had the necessary 
laboratory equipment and supplies to deter- 
mine the source and type of organisms produc- 
ing the various outbreaks of dysentery and 
other epidemic diseases. 

The following list indicates the '*G*' type of 
facilities provided: 



QJ2, 600-bed dispensary^ 

(j_4 200-bed dispensary^ 
100-bed dispensary 

(j_6 100-bed dispensary (mobile) 

(j_7 50-bed dispensary 

G-8 25-bed dispensary 

G-9 10-bed dispensary 

Q^IO 10-bed dispensary 

G-llA First-aid sub-dispensary 

G-13 Sub-dispensary — Dental 

G-14 Sub-dispensary — Dental (mobile) 

1 often after their arrival at an advanced base, some of the 
dispensaries were expanded to several times their original bed 
capacities. In some instances they became medical command ac- 
tivities known as fleet or base hospitals. 



Sub-dispensary — Dental Prosthetic 




Sub-dispensary — Dental Prosthetic 

lab (mobile) 



Malaria control component 



Epidemiology component 



Malaria and epidemic control com- 

ponent (l-G-18 plus 2-G-17's) 



Optical repair component, base type 



Optical repair component, mobile 




Rodent control ~ • ' . v 

The total cost of a fleet hospital of 1,000 
beds, including waterworks, sewage and gar- 
bage disposal plants, buildings, galley, laundry, 
shops, and other supporting facilities, was es- 
timated at $1,500,000. 

Extracontinental Medical Supply Storehouses 

These being primarily medical type installa- 
tions, CNO made BuMed responsible for plan- 
ning and coordination. The Brooklyn Medical 
Supply Depot and subsequently the Materiel 
Division therefore not only provided the medi- 
cal and dental material but made arrangements 
with BuDocks for buildings, utilities, and 
maintenance equipment and vehicles, with 
BuSandA for operational and administrative 
equipment and supplies, and with BuPers for 

Upon receipt of CNO activation orders, the 
Materiel Division was responsible for inter- 
bureau coordination to insure delivery of all 
materiel and personnel at tidewater in time to 
meet the shipping date. The Area Commander 
was responsible for assigning lift-tonnage and 
arranging for erection of the facility at desti- 

The Materiel Division, after consultation 
with the Professional, Dental, and Preventive 
Medicine Divisions of the Bureau and review- 
ing available medical intelligence reports, es- 
tablished basic item-quantity lists of common 
use medical and dental materiel. Supplemen- 
tary lists were made of additional items re- 
Quired in areas where various diseases were en- 

demic or where bad hygienic conditions were 

Each listing was estimated to provide stores 
for 10,000 men for 30 days. These MSS Load 
Lists were distributed to the continental Medi- 
cal Supply Depots and to the medical elements 
of Area Command logistic planning staffs. 
These lists were frequently adjusted to corre- 
spond with issue experience reported from the 
field. The Officer in Charge of each MSS was 
required to submit at least monthly by airmail 
recommendations for item eliminations or ad- 
ditions, item-quantity adjustments, and con- 
cise information relative to his operation and 
conditions in his area. 

The fastest method of getting a MSS into 
business was by automatic shipments at short 
intervals of a sequential series of these 
(10,000/30) load-lists. It was recognized that 
if issue experience did not correspond to fore- 
cast, stocks would promptly get out of balance. 
This liability was accepted, but corrective ac- 
tion was taken at the earliest opportunity; 
namely, when the OinC started his reports. The 
shorter the pipeline between continental depot 
and MSS the sooner the correction could be 
made, the MSS placed on a requisition basis, 
and automatic shipments cancelled. 



Medical Supply from Floating Outlets 

As mentioned earlier, medical supply of the 
fleet, the Fleet Marine Force, and overseas Ad- 
vance Bases from continental depots did not 
work out v^ell. This v^as particularly true of 
the fleet. With the frequent and often unpre- 
dictable movements of the numerous ships it 
was practically impossible to deliver the requi- 
sitioned shipment to the consignee within an 
acceptable period. Consequently, medical sup- 
plies on board reached such low levels that 
ship medical department effectiveness was seri- 
ously impaired. 

This inability of the fleet freight service to 
deliver shipments set up a vicious cycle of re- 
ordering which resulted in ever increasing 
quantities of material being immobilized in the 
pipeline. Thus, while the continental depots 
were being unnecessarily depleted of sorely 
needed stocks and the consumer was suffering 
from supply malnutrition, the pipeline swal- 
lowed everything and regurgitated very little. 
A great deal of this impounded and therefore 
useless materiel was composed of essential 
items in over-all short supply. Something had 
to be done to break this impasse. 

The Service Force, Pacific, (ServPac) 
started medical supply afloat during Septem- 
ber 1942 by putting moderate quantities of a 
limited list of items on board tankers. The 
space available for medical stores was limited. 
Tankers, however, did contact the fleet, they 
had a quick turnaround, and there were many 
of them. The results of this venture were very 
satisfactory. Not only did tankers give medi- 
cal stores to the fleet but on occasion they sup- 
plied sorely needed items to Advance Bases. 

Due to the limited space available on the 
tankers, it was decided to use other ships 
which regularly contacted the fleet, supplied 
items in universal demand, had an acceptably 
quick turnabout, and could afford sufficient 
space for storage and retail issue of a broad 
list of items. Another consideration was that 
there be enough, but not too many, of these 
vessels in the trade so that constant coverage 
could be effected but none of them would have 
to wait long periods before discharge. 

AK's fitted the pattern ideally. There we^^ 
however, only a few in operation at the tini^ 
so it was necessary to use some fast dry.pj.^^ 
visions AK's. Reefers were also tried for ^ 
while, but did not work out well due to the 
then slow turnaround and certain difficulties 
in breakout for retail issue. 

The so-called Medical AKS or Castor load 
was worked out to supply 100,000 men for 3(, 
days with a list of approximately 800 of the 
most essential medical and dental items. 

Due to the enthusiastic work of ship's medi. 
cal officers and hospital corpsmen, the cordial 
support of commanding officers, the helpful ad. 
vice and aid from supply officers, and wide 
broadcasting about this service throughout the 
fleet, the program was a spectacular success. 
Consequently, with the exception of hospital 
ships, all direct requisitioning on continental 
medical supply depots was abolished. If items 
not on the AKS Load List were desired, the 
ship sent the requisition to ServPac where, if 
it was approved, rapid supply was effected. 

As additional AKS's were commissioned, they 
had built-in medical store and issue spaces. 
With the increased number of AKS ships (this 
eventually reached 28) it was found advisable 
to reduce the AKS medical load to 60,000 men 
for 30 days' size. Each ship made a voyage 
issue report by airmail to ServPac. These re- 
ports recommended additions, deletions, or 
adjustments of quantities, and gave the num- 
bers and types of ships supplied together with 
other pertinent information. A constant run- 
ning analysis of these reports cumulatively 
provided the information upon which the load 
list was kept up to date. 

While the AKS program was being developed 
it became evident that an auxiliary service 
would be needed to cover gaps in the avail- 
ability of AKS issue ships at certain anchor- 
ages from time to time. To overcome this de- 
ficiency five barges with medical stores sec- 
tions were commissioned during 1943, and four 
additional barges in early 1945. These were 
really floating MSS's carrying over 1,500 item^ 



antity to supply 150,000 men for 30 days, 
^^^were anchored near fleet concentration 
h rages and Advance Bases, and supported 
' h on demand. Unlike a MSS built ashore, 
barge shipped its anchor when the war 
i^^fted and was towed to a more active area. 

where it was ready to start issues upon arrival. 
The importance of this mobility was demon- 
strated when barges were towed to Saipan, 
Manus, and Leyte from rear areas, and helped 
those localities mount out attack forces des- 
tined for still more advanced areas. 

Advanced Base Supply 

In the operations plans, ComServPac was 
charged with supplying all medical materiel for 
operations under the control of CincPac-CinC- 

With respect to Advance Bases, ServPac had 
the responsibility of planning all the details 
of the base buildup when the assault forces 
had secured the objective. Thus, all the medical 
department personnel, hospitals, dispensaries, 
sanitation, and other medical elements of the 
base had to be requisitioned, the shipments 
scheduled, and construction accomplished. In 
addition, medical supplies had to be furnished 
in sufficient quantities to provide current 
maintenance and stock level accumulation. 

Only the mechanism of furnishing medical 
supplies is pertinent to this article. This was 
accomplished by means of a variety of so- 
called Block Loads. The assault forces carried 
in with them quantities of materiel sufficient 
for their own needs and, with combat resupply 
shipments, had more than they consumed, so 
that there was always a sizable residue avail- 
able for the early advance base forces, when 
the Marines withdrew. Therefore the first au- 
tomatic block shipment for the Advance Base 
was usually scheduled to arrive about 10 days 
after the objective was estimated to be se- 
cured. With their own organic supplies to- 
gether with the assault residue, they had a 
good interim supply. 

Automatic shipments w^ere sent in at 10-day 
intervals and each shipment had enough sup- 
plies for 20 days for the personnel involved. 
Thus, the base accumulated 10 days toward its 
stock level, usually 90-days' supply, with each 
shipment. When it was calculated that the de- 
sired stock level was achieved, the automatic 
block shipments were reduced to maintenance 
quantities. The base was required to submit a 

monthly stock status report to ServPac at the 
earliest possible date and to get on a monthly 
requisitioning cycle as soon as possible, in 
order to even out the stock imbalances created 
by automatic supply. 

These monthly stock status reports were 
analyzed and were consolidated with those of 
all other bases. The tabulations were then used 
to adjust the block load lists to conform with 
experience. Three types of blocks were pro- 
vided for base forces: the Standard Mainte- 
nance Block, the Standard Maintenance Sup- 
plemental Block, and the Standard Mainte- 
nance Block, Dental. 

The Standard Maintenance Block contained 
balanced medical supplies sufficient for 3,000 
men for 30 days (weight 1^ long tons; 4 meas- 
ured tons). This was supplied by the Navy 
Medical Supply Depot, Oakland, Calif., through 
requisitions originated by ComServPac. The 
contents of the ''block'' were changed from 
time to time to conform to recommendations 
and suggestions made by the senior medical 
officers of the various bases, and in the target 

The Standard Maintenance Supplemental 
Blocks were used in conjunction with the 
Standard Maintenance Block to supply base 
forces in the developmental phase of a new 
base with additional supplies for combat cas- 
ualties. Such supplies were usually furnished 
for the first 30 to 90 days depending upon the 
estimated time required to secure the target. 

Standard Maintenance Blocks Dental — Dur- 
ing the early part of the war dental supplies 
were furnished in accordance with the strength 
of the forces to be supported and were a part 
of the standard block. In 1945 the dental block 
was developed, based on the number of dental 
officers rather than on the number of personnel 



to be served. Supplies in this block were suf- 
ficient for 10 dental officers for a period of 30 
days. This block was too large. A smaller block 
sufficient for 2 dental officers for 30 days more 
nearly met the needs of the forward area. 

Supplies for Military Governments^ 


affairs block was developed. This contained suf 
ficient supplies for 20,000 civilians for 30 day* 

TJr\e-rvifQ 1 Kckrla tttqt^o YMTkTri rl cirl \\-\t **Q-'* 

Hospital beds were provided by 
ponents housed in tents. 


Marine Combat Supply 

As was mentioned early in this article, 
Marine combat supply during the early phases 
of the war in the Southwest and South Pacific 
was effected from MSS's in those areas. Later 
in the Southwest Pacific the Marines derived 
logistic support from the Army. In the South 
Pacific the MSS's afforded support to Marine 
combat forces through July 1943. Thereafter 
Marine combat supply in the Central Pacific 
was the responsibility of ComServPac. Thus, 
through the Saipan-Guam operations ServPac 
provided directly the medical materiel to mount 
out the MarCorps, for combat resupply, and 
for the rehabilitation of the combat forces at 
the staging area upon completion of the assault 
operation. Subsequent to Guam the FMF or- 
ganized Medical Stores Sections in their Depots 
and Service Regiments under the control of 
the Force Surgeon, and did most of the detailed 
medical materiel planning. They submitted 
requisitions to ServPac, which arranged for 
the delivery of the materiel where requested, 
either into combat shipping at United States 
ports, or at the mounting out area, or in ships 
at the target, or lastly at the rehabilitation 

MarCorps service elements received and dis- 
tributed this material together with other cate- 
gories of suppHes for Marine Forces. There 
were Medical Supply Sections in the Sixth 
Service Base Depot in the Hawaiian Area, the 
Fifth Service Field Depot on Guam, the 
Eleventh Service Battalion on Saipan, and the 
Twelfth Service Battalion on Okinawa. These 
sections stocked field medical units and bulk 
medical supplies. Resupply was obtained from 
Naval Medical Supply Depots and Storehouses 
via ComServPac. 

The initial medical supply scales (blocks) 
were based on those used by ServPac. The 
scales, which were based chiefly on usage rates, 
were altered from time to time on recommenda- 

tions from the field. These scales acted as a 
guide to the division or other medical officers 
for preparation of requisitions for submission 
to the Medical Supply Section of the Marine 
Supply Depots. 

The Fleet Marine Force Rehabilitation 
Medical Block was 30 days' bulk supplies for 
3,000 men. Blocks were varied according to the 
type of organization and to meet particular 
situations; the number of blocks was in pro- 
portion to the number of troops supplied. From 
20 to 50 percent of medical field units were 
required to reoutfit Marines following combat 
In other words the loss of medical field units 
during each major engagement was from 20 
to 50 percent. 

The Fleet Marine Force Maintenance Block, 
contained sufficient supplies for 3,000 men for 
30 days, and was used following the cessation 
of combat and also while reoutfitting and re- 
forming for the next operation. 

Reserve or combat back-up. -The^e were 
block supplies held in cargo ships anchored at 
advance bases ready for quick transit to the 
combat zone in case of loss or depletion of the 
initial and combat resupply shipments. Combat 
resupply was also based on the needs of 3,000 
men for 30 days. The medical personnel at- 
tached to the Headquarters Service Command 
prepared requisitions based on directives re- 
ceived from CinCPac-POA for combat resupply 
to be shipped to the target at stated intervals. 
Such requisitions were forwarded by ComServ- 
Pac to the Navy Medical Supply Depot, Oak- 
land, with the necessary instructions as to 
packaging and time of delivery. The Depot 
Quartermaster, San Francisco, specified place 
of delivery and was responsible for loading. 
The medical supplies, as well as other combat 
resupply, were divided equally among the ships 
assigned for Marine Force use. 



(jorps Evacuation Hospital-Fleet Marine 
VQYce three corps evacuation hos- 

tals. Pi'ior to each operation one or two of 
these hospitals were assigned to the corps head- 
uarters and one was held in reserve. Each had 
I capacity of 600 beds. 

Hospital Ships carried a reserve medical 
company outfit which could be landed as re- 
quired. A reserve supply of these medical com- 
pany outfits was held at Pearl Harbor and 
Guam, packed and ready for immediate load- 

Waterproof Packing.-ln the early stages of 
the war medical materials packed for domestic 
commerce were shipped and off-loaded onto 
beaches and held in open storage. This exposed 
medical material to the elements and resulted 
in damage and losses of considerable magni- 
tude. This loss continued until methods of 
waterproofing were devised and manufacturers 
and depots could obtain the necessary water- 
proofing materials. By early 1943 supplies were 
waterproofed before being sent to combat 
areas. Later, supplies for the frontlines were 
waterproofed and palletized on sled pallets. 

Whole Blood for Transfusion 

The first shipment of whole blood to the 
Pacific left the West Coast for the Whole Blood 
Redistribution Center, Guam, on 16 Novem- 
ber 1944. Machinery had been set up for re- 
icing at Pearl Harbor and Kwajalein and for 
handling at Guam. All whole blood was shipped 
from the West Coast via air to Guam. The 
Center on Guam reexamined all shipments, 
discarding containers showing excessive de- 
struction of red blood cells or evidence of con- 

Prior to an amphibious operation, hospital 
ships were provided with blood for distribution 
to the forces taking part in the operation. LST 
929 was specially outfitted with reefers for stor- 
ing blood and with equipment for making the 
ice required for packing it. Further, reefer 
mounted trucks transported blood to the mobile 
blood bank and to the front. The Marines used 
a mobile blood bank for the Iwo Jima and Oki- 
nawa operations. At a later date each Marine 
division was supplied with a mobile blood bank. 

Materiel Shortages and Defects 

Every effort was made by MatDivBuMed to 
provide Navy Medical Supply Depots with suf- 
ficient supplies to support all naval forces in 
the United States and overseas. At one time or 
another, however, various items were in short 
supply throughout the service. The medical 
supply depots prepared and forwarded to over- 
seas Area Commands a list of shortages and 
estimated dates of item availability. Many 
special items were disallowed because they were 
not essential. Essential items in short supply 
Were controlled and issue restricted to those 
considered most needful. 

In the fall of 1943, criticisms of the equip- 
nient supplied to fleet hospitals were received 
from the South Pacific, following which the 
Commander, South Pacific established a board 
to standardize fleet hospitals. In accordance 

258015—53 12 

with the findings of the Board, it was agreed 
that Bureau of Yards and Docks would develop 
plans based on preliminary architectural draw- 
ings provided by Medicine and Surgery, and 
that the Bureau of Yards and Docks and the 
Bureau of Supplies and Accounts would pro- 
vide nonmedical materials not in Bureau of 
Medicine storehouses, for Fleet Hospitals 114, 
115, and 116. 

Hospital beds were provided for all new 
bases in the form of ''G" components or fleet 
hospitals. The absolute minimum requirement, 
for the base to be self-supporting, was 2 beds 
for 100 of population. An average of 3.5 beds 
were supplied by the Navy. In estimating the 
bed requirements for new bases, consideration 
was given to the prevalence of tropical diseases 
such as dengue, malaria, and dysentery, and to 



the density of the native population. The larger 
the number of natives present, the greater the 
danger of outbreaks of disease among the 

The above is of course only a summary of 
the highlights of medical supply during the v^ar. 
Readers interested in making a detailed study 
of medical materiel logistics are referred to 

current operating manuals. These publication, 
include the refined concepts, techniques, 
operational practices now in use and develop^ 
as a result of the experiences of World War H 
It is our hope and belief that v^e v^ill not, 
the next emergency, have to take all the falter^ 
ing steps we did in the past, but be ready 
adequate and tested mechanisms to meet am- 

Chapter V 

Development of Medical Services 
for Marine Corps Forces in the Field 

French R. Moore, Captain (MC) USN 

Before World War II this nation had never 
participated in any war that necessitated the 
capture of strongly defended island bases or 
large land masses on which an opposed landing 
had to be made. Nor was there much to be 
gained by studying previous military engage- 
ments of other nations. Historically, the only 
opposed landing had been at Gallipoli, and this 
was far from successful. 

The Fleet Marine Forces, in conjunction with 
the fleet, had made numerous practice landings 
on islands in the Caribbean area. Although the 
forces actually landed were small, the lessons 
learned proved invaluable, particularly those 
taught by experiences in loading supplies, 
equipping vessels with medical supplies, and 
evacuating casualties. Unfortunately, these land- 
ings never included a protracted operation 
ashore. Had this been done, the problems of 
messing, sanitation, and long lines of evacua- 
tion would have become apparent. Fortunately, 
the Bureau of Medicine and Surgery in 1937, 
established a board to study, modify, and de- 
velop the medical equipment and supplies con- 
sidered necessary for the support of a Marine 
Division in a combat landing. Even though the 
equipment procured was based on experiences 
in World War I, such a study proved to be of 
value as the equipment developed w^as fairly 

The First and Second Marine Divisions were 
activated in the fall of 1941 and early in 1942. 
The personnel of these divisions comprised 
some of the best officers and men of the regu- 
lar Marine Corps, plus Reserves and Volun- 
teers. Their spirit was excellent and they went 
^wholeheartedly into their training. The medical 
Personnel consisted of a few regular medical 

officers and Hospital Corps personnel, plus Re- 
serve medical officers and volunteer corpsmen. 
None of the volunteer corpsmen had ever re- 
ceived any Hospital Corps school training, and 
most of them were uninformed regarding the 
supplies, equipment, and function of the Medi- 
cal Department. The Medical Department 
lacked automotive equipment, surgical instru- 
ments, and an adequate allowance of medical 
personnel for frontline troops. Necessary surgi- 
cal equipment and supplies were secured from 
local hospitals, but additional automotive equip- 
ment and personnel did not become available 
until late in the Guadalcanal campaign. In the 
4 months that intervened between the activa- 
tion of the division and the departure of the 
Second Marine Division for Guadalcanal, the 
training was intensive and thorough. All corps- 
men were instructed in the technique of admin- 
istering plasma, adequate splinting, and the 
control of hemorrhage. Dental officers were 
trained in administering anesthesia and also to 
work as a team with the otorhinolarynogolo- 
gists in treating gunshot wounds of the jaws 
and face. 

The result of the time and effort spent in this 
training w'as evident in the high efficiency of 
the Medical Department personnel. A few 
practice landings made on the beaches of south- 
ern California had been helpful, but here again 
the troops never made any extended stay ashore 
and therefore many valuable lessons were 

Realizing the deficiencies of automotive 
equipment and personnel for evacuation, a jeep 

was secured and with minor alterations con- 
verted so that it could carry two stretcher cases, 



two sitting wounded, and the driver. This de- 
sign was submitted to the Marine Corps Head- 
quarters who unfortunately, rejected it. It was 
resubmitted and later approved, but not in time 
to take the necessary number of jeeps to the 
battle area. Just prior to embarking for 
Guadalcanal, two jeeps were allotted and neces- 
sary alterations were made locally. These two 
vehicles proved invaluable, but many more 
could have been used. In the late stages of the 
Guadalcanal campaign, five factory modified 
jeep-ambulances arrived at Guadalcanal and 
were immediately recognized by all as a vital 
means of evacuation of wounded in small island 

There was no information available to the 
Medical Department concerning the place and 
time of the Guadalcanal landing or regarding 
the supporting medical services in the rear. 
The National Geographic Magazine furnished 
the best source of information concerning the 
south sea islands, together with a report from 
the Malarial Commission of the Rockefeller 
Foundation covering the period from 1930 to 

The menace from malaria was evident from 
the Rockefeller report, but the only protection 
against mosquitoes was the clothing worn, a 
head net, and a cot-type mosquito net. It was 
futile to issue nets to frontline troops because 
the only personnel who could use them were 
those in rear areas and field hospitals. Accord- 
ingly, all available quinine powder and tablets 
on the Pacific Coast were secured. Many types 
of capsules for powdered quinine were tried, 
but they all congealed in temperatures over 
90° F. The quinine powder, therefore, had to be 
taken in bulk form. This proved to be a great 
handicap in the administration of prophylactic 

In addition to large amounts of quinine, a 
sufficient amount of brandy in 2-ounce bottles 
for medical use for 5,000 men for 6 months 
was obtained. This brandy reduced the inci- 
dence of war neuroses during the campaign. 
When estimating other supplies, the treatment 
of casualties occurring in naval vessels in our 
vicinity was anticipated and additional supplies 
of blood plasma and large battle dressings were 

We embarked on 1 July 1942 and on 7 ^ 
ust 1942 the First Marine Division reinfoi-^.^ 
landed on Guadalcanal, Tulagi, and adjac^ 
small islands. The landing at Guadalcanal 
virtually unopposed, so all personnel and equij^ 
ment got ashore and the medical units becauj^ 
well organized before much enemy resistance 
was encountered. At Tulagi, the situation w?. 
different; there was stiff enemy opposition ani^ 
casualties were moderately high for 3 days, | 
was here that the medical department met it 
first real test. Fortunately, the island was siria 
and lines of evacuation short, so that all cas. 
ualties reached their combat transports within 
a short time after being wounded. 

Two major defects were noted : First, there 
were no blackout aid stations where a patient 
could be treated at night and evacuated. Later, 
some first-aid stations obtained excellent black- 
out tents which were designed at the Field 
Medical Research Laboratory in Camp Lejeune, 
N. C. The second defect was that line officers 
and men alike disregarded all rules of sanita- 
tion. When the local water supply was destroyed 
during the engagement, personnel drank water 
from any source. The dead, both our own and 
the enemy, could not always be buried without 
some delay because of battle conditions. Human 
excreta w^as deposited indiscriminately and this 
materially increased the number of flies. Within 
a week diarrhea appeared. It was fortunate that 
the enemy had no forces to counterattack at 
this time. 

As a whole, the medical aspects of the oper- 
ation were successful. Particularly, the death 
rate from wounds was low because adequate 
amounts of plasma and sulfonamides were 
administered early. On Guadalcanal, because of 
the larger land mass, defects in sanitation were 
not penalizing. Within a few weeks after land- 
ing on Guadalcanal, malaria was prevalent, but 
the adequate amount of quinine and some ata- 
brine on hand permitted thorough treatment. 

In September the Malaria Control Officer on 
the Staff of Commander, South Pacific, advised 
the use of atabrine (four tablets per week) as 
prophylaxis. This was difficult to inaugurate as 
word got around that atabrine damaged the 
liver and decreased sexual powers, but by dili- 
gent effort this fear was gradually overcome. 



T)ite of atabrine prophylaxis, the number of 
, of malaria continued to increase. By No- 
^ember 1942, 16 percent of the combat troops 
ineffective — 4 percent from wounds and 
percent from malaria. Beginning on 15 No 


one tablet of atabrine per day was 


to men in the Second Regiment. Within 
♦Mveeks the number of admissions for malaria 
decreased over 50 percent. This dosage was not 
approved by the Malaria Control Officer and 
^^.^g not reported at this time because of specific 
instructions not to give more than 4 tablets 
per week. After 1 December, all Marine troops 
coming into the area w^ere given one atabrine 
tablet per day, and from then on the number 
of ineffectives among the combat troops be- 
cause of malaria was less than 5 percent. A 
small supply of mosquito repellant, ''Skat," was 
provided in the middle of December, but be- 
cause it produced skin irritation and evap- 
orated rapidly, it was not utilized effectively. 

During the Guadalcanal campaign it was 
early discovered that giving plasma and blood 
in one or two veins was not sufficient to over- 
come the severe shock and blood loss that fol- 
lowed gunshot wounds of the liver and kidneys. 
As a result, all patients with liver and kidney 
wounds were given infusions through the veins 
of all four extremities simultaneously. Plasma 
was given in both arms and one leg, and saline 
and glucose in the other leg. While this was 
going on, blood donors were secured from 
troops in rear areas and, as soon as cross 
matching was completed, citrated blood was 
substituted for the plasma. The first patient on 
whom this new technique was employed was 
an aviator who had sustained a wound extend- 
ing from the twelfth dorsal vertebra around 
nearly to the umbilicus, seeming to cut him 
almost in two. Someone had jammed a shirt 
into his side, on which pressure was maintained 
to stem bleeding. When he arrived, no pulse 
could be felt in the wrist and it appeared that 
the patient was dying. The *'four-way'' infusion 
described previously was started after cutting 
down on the veins in all four extremities — the 
Petcocks on the infusion sets were opened wide. 
Within 15 minutes the pulse appeared at the 
y^ht Blood was substituted for the plasma and 
in an hour and a half the blood pressure had 

risen and stabilized around 110/70. The trans- 
fusion was continued for another half hour and 
the patient was prepared for surgery. During 
this period of preparation the patient received 
8 units of plasma, 9 pints of blood, and 2,000 
cc. of saline dextrose — a total of 11,500 cc. in 
2 hours. This patient made a complete recovery 
despite his very extensive injury, which also 
involved the kidney and colon. This is believed 
to be the first time that a *'four-way'' trans- 
fusion had ever been used and that such large 
amounts of plasma and blood had been given 
in such a short interval. This *'four-way'' trans- 
fusion was later used successfully on other 
patients with wounds of the liver and kidney. 

In the forward areas patients with burns 
were treated with 5 percent sulfanilamide oint- 
ment locally, pressure dressings, plasma, saline, 
and dextrose. About 24 hours after the sink- 
ing of one of our large aircraft carriers, 76 
patients who had second degree burns of from 
30 to 50 percent of their body surface were re- 
ceived. Many of them had been burned while 
swimming through flaming oil. The burned 
areas involved the legs, arms, upper chest area, 
and face. Each patient received an average of 
4,000 cc. of plasma and 2,000 cc. of saline and 
dextrose via the femoral vein, during the first 
72 hours. All these patients were treated in a 
field hospital for 2 weeks before they were 
evacuated. There were no deaths. Because the 
burned and wounded areas were clean, no sec- 
ondary infection was evident at the end of 2 
weeks. This is believed to have been the first 
time that severely burned and wounded patients 
had been treated with sulfanilamide ointment 
and plasma under combat conditions. Under 
field conditions, when a large number of casual- 
ties were received, it was impossible to admin- 
ister sulfonamides or other drugs either orally 
or parenterally because sufficient medical per- 
sonnel were not available. 

Keeping a record of the casualties evacuated 
from a combat area is one of the most im- 
portant functions of the Medical Department, 
both in the forward and rear areas. In the for- 
ward area the record simply listed the name, 
rank or rate, serial number, diagnosis, and date 
of evacuation. Unfortunately, because of lack of 
coordination in the rear areas, large numbers 



of patients were lost track of and it was most 
difficult to find out if personnel had been evacu- 
ated to the United States or if they were still 
in base hospitals in the rear. When health 
records, pay accounts, service records, and per- 
sonal effects were left in the rear areas, it 
became a tremendous task to try to get the 
patient, his personal effects, and records to- 
gether. Although attempts were made to estab- 
lish casualty clearing sections in later cam- 
paigns, the problem was never adequately 
solved. A thorough study of casualty recording 
and reporting should be made and an adequate 
system developed so as to prevent a repetition 
of this confusion. 

Establishing a satisfactory operating room 
during combat was found to be particularly 
difficult with the equipment provided. This in- 
cluded a tent, a light portable operating table, 
and a battery spotlight. The tents could not be 
blacked out and there was no protection against 
flies and mosquitoes ; so that clean surgery was 
impossible. A portable plywood hut (16' by 16') 
was finally secured from an aircraft tender 
and this proved to be ideal for an operating 
room. This hut, known as the "Dallas Victory 
Hut," was well screened, had a good solid oak 
floor, and flaps for blacking out. Following the 
Guadalcanal campaign, each medical company 
was provided with one of these portable operat- 
ing rooms. In the later campaigns it was found 
possible, by presterilizing instruments, to have 
the portable operating room set up and func- 
tioning within 6 hours following the landing of 
a medical company. 

In 1944 the Marine Corps Headquarters 
asked several contractors to design a portable 
plywood hut, 16' by 16'. As a result 16' by 16' 
huts that weighed about 1,200 pounds were 
manufactured. These could be erected in 2 
hours by 4 men, and could be shipped in a 
package 4' by 4' by 8'. Future developments 
along this line should be encouraged, as these 
plywood operating rooms proved to be the only 
way that major surgery could be carried out 
satisfactorily in the field. 

Medical Department brandy was first used in 
the field in the Guadalcanal campaign to combat 
fear and combat fatigue. Each aid station and 
field hospital was provided with brandy so that 

the medical officer could administer this to 
who manifested early signs of fear or coi!Iv? 
fatigue. Four ounces of brandy were addej 
each canteen of water and two or three ^J^; 
lows of this given to a dehydrated patient 
an empty stomach) was usually sufficient to * 
duce a sound sleep. Following this, he ^ 

be ready for the frontlines again. With sodJ 
patients this procedure had to be repeated t^ 
or three times ; in no instance did a patient tr! 
to take improper advantage of the medicatio^ 

Near the close of the Guadalcanal campaig^j^ 
a Medical Department combat landing plan 
designed. This plan listed the supplies auj 
equipment to be landed with each medical unit 
and showed a diagram of the Medical Depart^ 
ment personnel and lines of evacuation from 
the frontlines back to the rear areas and 
evacuation points. It was a great aid in coordi- 
nating the medical activities in a division and 
also provided for better teamwork between the 
forces ashore and the supporting amphibious 
forces. This combat landing plan was later usee 
with slight modifications by the Marine Corps 
divisions and was also used as a training guide 
in the Field Medical Schools. 

The First and Second Marine Divisions were 
sent to Australia and New Zealand, respec- 
tively, for reoutfitting and reorganizing. Up 
arrival, the weather was cold and rainy an( 
there was not enough coal available to ade- 
quately heat the living quarters. Six weeks fol- 
lowing their arrival, the Second Marine Di- 
vision had an average of 250 admissions for 
malaria each day from among the 13,000 men 
who had been in the Guadalcanal area. This 
high admission rate severely taxed the field and 
the base hospital at Wellington. Had there been 
more information on the prolonged use of ata- 
brine as a suppressive agent, this high admis- 
sion rate could have been materially reduced 
However, no suppressive therapy was used and 
each admission was treated with quinine or var- 
ious combinations of quinine and atabrine. Ata- 
brine therapy alone was also used. In spite of 
the various antimalarial drugs used, the admis- 
sion rate remained high. In two battalions that 
had been in the Guadalcanal area therapeutic 
studies were started under similar conditions 
for an equal length of time. In one battalion 



^'ly admitted malaria patients were given 
^rains of quinine for 10 days, followed by 
^ ains for 30 days. In the other battalion 
new admissions were given 6 tablets of 
! brine for 3 days, 3 tablets a day for 7 days, 
f llowed by 1 tablet a day for 30 days. These 
ttalions were observed for 2 months. In the 
h^talion receiving atabrine, the recurrence rate 
- nearly 70 percent less than in the battalion 
ceiving the quinine. This was convincing evi- 
dence that, of the two, atabrine was the drug 
of choice in treating malaria. In the recurrences 
nearly all smears disclosed Plasmodium vivax; 
in a few patients a mixed infection with Plas- 
modiion malariae and P. vivax was noted. Four 
months after leaving the Solomon Islands, how- 
ever, all smears revealed only P. vivax. 

In July 1943 the Second Marine Division 
received orders to prepare for the attack on 
Tarawa in the Gilbert Islands. The Division 
Surgeon was one of the 8 staff members included 
in the advance planning. All medical sections 
were thoroughly indoctrinated in the Medical 
Combat Landing Plan and intensive drills were 
held, both day and night. Medical supplies, 
which were rather difficult to secure, were fin- 
ally obtained, including 6,000 units of plasma. 
All corpsmen were trained to give plasma. Boat 
bags were procured and packed with essential 
first-aid items, such as battle dressings, plasma, 
sulfanilamide powder, and splints. These bags 
proved to be a great aid in landing medical 
supplies, for corpsmen could easily carry this 
bag ashore, in addition to their personal equip- 

As no amphibious force surgeon was present, 
the division surgeon was assigned the additional 
duty of training and coordinating the medical 
departments of the transports. This was of 
value in the operation of the plan, as all Medical 
Department personnel from the f rontlines back 
to and including the transports knew what their 
functions were and how other units were to 

All personnel landed were thoroughly indoc- 
trinated in the proper disposal of galley waste 
and human excreta, and all drinking water was 
placed in cans and salted just prior to the land- 
ing. As a result, there were no admissions for 
gastrointestinal complaints. There were, how- 

ever, a few admissions for heat exhaustion in 
one battalion because they failed to carry out 
the order to salt the drinking water. - . 

Intelligence reports indicated that there were 
approximately 4,000 enemy troops on Tarawa. 
From experience in previous operations it was 
realized that the bodies of nearly all of the 
4,000 enemy troops would have to be disposed 
of in addition to our own dead. Three methods 
of disposal of the dead were considered. The 
first idea was to take all bodies out to sea and 
weight them for sea burial. This was considered 
to be impracticable because of the large number 
of boats and working parties required. Second, 
cremation of the enemy dead was considered, as 
this was the common practice of the Japanese, 
but this, too, was impracticable because of the 
large amounts of fuel oil necessary and the 
length of time required for cremation. The 
method of disposal finally evolved was burying 
our own dead in long graves made by bulldozers 
and the enemy dead in bomb craters which 
were then covered over by bulldozers. This 
proved to be satisfactory although the water 
level was only 6 feet below the ground level. 
The plan was well conceived but was carried 
out under great difficulty. Most of the bodies 
had been exposed to the heat for from 4 to 7 
days, and the odor was almost beyond human 
endurance. Within an hour the working parties 
of 300 men would become so nauseated they 
could not continue working. Within a week, 
however, all exposed bodies on the island were 
buried. This disposal of the dead had to be 
carried out by the assault forces who were 
already exhausted by 4 days and nights of a 
terrific fight. They readily helped in burying 
our own dead, but were bitterly opposed to 
burying the enemy dead. In conference with 
the high Naval Command in Pearl Harbor, 
following this attack, it was finally agreed that 
in future operations a battalion, in conjunction 
with the grave registration units, Seabees, or 
other personnel, should be assigned the sole 
duty of disposing of the dead. 

On 20 November 1943 the attack on Tarawa 
was started. One hundred and twenty-five am- 
phibious tractors were utilized in landing the 
initial assault companies. Casualties in the 
assault companies ranged from 50 to 70 per- 




cent. By noon of D-day about 300 troops had 
secured a small area on Red Beach 2, adjacent 
to the pier. A small number of troops were 
landed on this beach in the afternoon and even- 
ing of D-day, and by the morning of D-day- 
plus-1 about 100 yards of the beach had been 
secured but only to a depth of 25 to 75 feet. 
During this period the only medical supplies 
available were those that were carried in by 
Medical Department personnel in kits or boat 
bags. Because of the terrific number of casual- 
ties, no organized evacuation could be effected 
at this time, but casualties were evacuated as 
rapidly as possible by any and all hands avail- 
able. They were taken directly to AP's through- 
out that day and night by amph-tracts or any 
other type of boat at hand. By the morning 
of D-day-plus-1, the main points of evacuation 
had been established and were functioning 
smoothly. On D-day-plus-1, additional troops 
began to land, additional medical supplies had 
been secured, and all casualties were receiving 
adequate amounts of plasma before being evac- 

Approximately 2,500 casualties were evac- 
uated during the 4 days of the attack. During 
this time nearly 4,000 units of plasma were 
used, or an average of a little less than 2 units 
of plasma for each casualty. A large percentage 
of the plasma was administered by corpsmen. 
The time spent in training corpsmen to give 
plasma contributed largely to keeping the death 
rate at the low of 2.3 percent of those wounded. 

On D-day-plus-2, Companies "A'' and "B'' of 
the Second Medical Battalion were ordered 
ashore on Betio and Bairiki Islands, respec- 
tively. Both of these companies established 
operating room facilities and were ready to 
operate 6 hours after landing. 

Many casualties arrived aboard the transports 
within 1 hour after being wounded although 
some were not received until as long as 12 
hours after being hit. The low death rate of 
2.3 percent during the Tarawa campaign was 
due to the following factors: First, the heroic 
work of the medical officers and corpsmen under 
terrific odds ; second, the use of large amounts 
of plasma during the evacuation; and third, 
the thorough indoctrination of all medical per- 

sonnel, including those in transports, in 
medical plan. 

The plan to have a senior medical officer froij^ 
the Transport Divisions on the control ship to 
properly distribute the patients to the tranj. 
ports was not carried out in the Tarawa opera, 
tion. This resulted in the overloading of several 
transports ; some received from 50 to 75 casual, 
ties in an hour or two. This caused some delay 
in treatment. It is essential that a senior med. 
ical officer, thoroughly acquainted with the 
capacity and capabilities of the staff of each 
transport, be assigned to the control ship. 

The use of APH's in an attack was considered 
highly desirable, as this type of ship could carry 
in assault forces and also had a complete staff 
of specialists and large sickbays, so that 
specialized treatment could be provided. The 
use of AH's was also highly desirable, but since 
they could not go into the transport area until 
D-day-plus-1 or later, it was seldom possible 
for them to receive casualties directly from 
the beaches. Their main function, therefore, 
was that of relieving the overloaded transports 
of casualties for evacuation to base hospitals. 

In the Marianas campaign, an attempt was 
made to use medical officers aboard control ves- 
sels. These medical officers were not assigned 
until the last minute and as a result did not 
know the capability of the medical sections and 
capacity of the transports employed. Air evac- 
uation from the Marianas campaign was 
started on D-day-plus-14. At first, the casualties 
were not properly screened and many were evac- 
uated by air who were in poor condition. This 
resulted in several near fatalities. In the Gua- 
dalcanal campaign, all casualties who were to 
be evacuated by air were properly screened and 
all arrived at the base hospitals in good con- 

The Medical Department with the landing 
forces in the Marianas functioned in a highly 
commendable manner. Unfortunately, many of 
the jeep ambulances assigned to the divisions 
were not loaded and as a result, evacuation of 
of casualties from the forward areas was un- 
necessarily delayed. In the Marianas campaign 
it became apparent that mobile surgical units 
were necessary if the Medical Department was 



keep up with the rapidly advancing attack, 
r llowing this operation, recommendations 

ere made for a complete mobile surgical unit. 
To meet this need, the Bureau of Medicine and 
Surgery and the Marine Corps developed an 
air-conditioned surgery complete v^ith steriliz- 
ing equipment in a trailer, 8 by 18 feet. The 
Marine Corps furnished the trailer v^ith air- 
conditioning equipment and the Bureau of Med- 
icine and Surgery furnished the sterilizer bank, 
operating table, operating lights, and all types 
of surgical equipment. Because all units to go 
into this trailer had to be specially designed and 
manufactured, it was nearly 1 year before these 
surgical trailers reached the field. They were 
not delivered in time for the Iv^o Jima or 
Okinawa campaigns, although they were ready 
for the attack on the Japanese mainland. The 
continued study and improvement of such 
mobile surgical units is highly desirable. 

As a result of the experiences in the Tarawa 
and Marianas campaigns, amphibious trailers 
originally designed by the Marine Corps to 
land essential supplies and equipment were con- 
verted into armored amphibious sickbays. 
They offered protection from shrapnel and 
small-arms fire to the casualties in battalion 
and regimental aid stations, and could be loaded 
with large amounts of supplies and medical 
equipment. Hauled ashore by amphibious trac- 
tors, they were immediately available to prop- 
erly care for a large number of casualties. 
Armored amphibious sickbays were considered 
to be a prime requisite in handling casualties 
near the frontlines. If such aid stations had 
been available at Tarawa, adequate medical 
supplies would have been available early, even 
if only one or two were successfully landed. 
They certainly would have been ideal for the 
landing at Iwo Jima, where the aid stations 
on the beaches were under fire for several days. 

After the Guadalcanal and the Tarawa cam- 
paigns, it became evident that certain addi- 
tional medical and surgical specialists should be 
assigned to the Marine Corps Divisions. In 
response to requests coming in from the field, 
one psychiatrist and one ophthalmologist were 
added to the Headquarters Company of each 
Medical battalion. In the Iwo Jima campaign, 
^he operations reports indicated that the psy- 

chiatrists were able to segregate and control 
evacuation of all neuropsychiatric patients. This 
took a great workload off other medical officers 
who were then able to concentrate on the care 
of the wounded. The work of the ophthalmol- 
ogist also afforded much better care for those 
with eye wounds. 

The Hospital Corps pouch furnished to the 
medical personnel attached to the Marine Corps 
was too narrow and too deep. Following the 
Tarawa operation, a study was started at the 
Field Medical Research Laboratory at Camp 
Lejeune on developing and improving the Hos- 
pital Corps pouch. A modification of the Navy 
Hospital Corps pouch was developed and 
adopted, which made all supplies accessible, 
with separate compartments for morphine 
syrettes and other small items. 

The sick call cases furnished with the field 
medical equipment early in the war were found 
to be highly unsatisfactory. These were simply 
fiber suit cases which were easily broken and 
were not waterproof. When they were opened, 
the contents were found scattered. Late in the 
Guadalcanal campaign and following it, the 
standard Marine Corps field desk was converted 
to sick call cases. Separate compartments were 
built into these field desks for standard size 
ointment jars and bottles. When the desk was 
opened up and the legs extended, the needed 
equipment was immediately available. This 
sick call case was later modified at the Field 
Medical Research Laboratory and became a 
part of the field equipment issued to all Medical 
units with Marine divisions. 

Although we had entered World War II 
with no experience in the employment of med- 
ical units in an opposed amphibious landing, 
we had learned a great deal by the spring of 
1943, as is shown in the following order issued 
on 1 April 1943: 


Employment of Medical Units 
The following are basic instructions for the 
Amphibious Employment of medical units of 
this Division: 

Si, Medical supplies: 
(1) Combat loaded. 



(a) Initial requirements to be avail- 
able for debarkation with medical personnel. 

(b) Remainder to be unloaded with 
combat team material. 

b. Medical personnel: 

(1) Combat loaded, 
(a) Combat team and landing team 

personnel normally will be with their original 
Headquarters (Annex "A"). 

(2) Will be equipped with shoulder 
holster and a pistol for self-defense when 


SL, Medical personnel ivill land as folloivs: 

(1) In approximately the same wave 
as Headquarters to which attached. 

(a) Company Aid Corpsmen. 

(b) Battalion Aid Station. 

(c) Regimental Aid Station. 

(d) Medical personnel with Division 


(2) Earliest possible time following 
Shore Party Command Group: 

(a) Shore Party Medical Personnel. 

(b) Collecting Section. 

(3) When tactical situations permit, 
(a) Hospital Section. 
(&) Medical Battalion. 

(c) Malaria Control Unit, 
b. Supplies and Equipment (paragraph 



a. Company Aid Corpsmen will give 
wounded emergency treatment in Company 
Zone of Action. 

b. Battalion Aid Station will evacuate 
casualties from frontlines to Battalion Aid 
Station, treat and prepare casualties for future 

c. Regimental Aid Station will establish 
near Regimental Command Post and along line 
of drift from Battalion Aid Station. 

d. Landing Team Shore Party (Medical) 
will be composed as follows: 

(1) Collection Section Medical Com- 
pany: 1 Medical Officer, 11 Corpsmen, 3 Ma- 
rines, and 1 Jeep Ambulance (combat loaded). 

(2) Pioneer Platoon: 1 Corpsman. 

(3) APA: 1 Medical Officer, 8 Corps. 


e. The following are assigned duties 
Shore Party Aid Station : 

(1) Medical Officer (Collecting Sect^ 
Medical Company) : Segregation and treatm. 
of patients at Shore Party Aid Station. 

(2) Medical Officer (Pioneer Compam 

(a) Coordination of evacuation > 
tions and report to Division or Shore Party 
Commander on evacuation. 

( b ) Treatment of casualties occurring 
in his immediate area. 

(c) Designation of Corpsmen to re- 
cord patients evacuated to APA and also l 
Corpsman on APA to record patients received 
(Data to include name, organization, diagnosis, 
and serial number.) 

(3) Medical Officer (Collecting Section) 
and Medical Officer (Pioneer Company) : Litter, 
blanket, and splint exchange. 

(4) Medical Section (APA) : Evacua- 
tion by boat to APA, and in addition assist 
Company 1 Section. 

f. Collecting and Shore Party Medical 
Personnel : Establish such emergency Field Hos- 
pital as necessary to care for casualties after 
the APA's depart and before Hospital Section 
can establish Field Hospital. 

g. Hospital Section : Set up Field Hospital, 
receive, treat, and separate casualties for evac- 

h. Medical Battalion (less 3 companies): 
(1) Establish Division Hospital and be 

prepared to receive, treat, and evacuate pa- 
tients from units in the area, or to relieve 
other Medical Companies v^hen necessary. Their 
ambulances w^ill be available to aid casualty 
evacuation from all units, which they serve. 
When established, the follov^ing v^ill be notified: 

(a) Division Surgeon via Command- 
ing Officer, Medical Battalion. 

(6) Any unit served. 

i. Malaria Control Unit will unload on 
order. For duties, see Senior Officer Present, 
Malaria Control. 




Employment in Combat: 

(1) No Medical Officer will be assigned 
to a unit smaller than a Battalion except Med- 
ical Officer in Pioneer Battalion. 

(2) Medical Officer will remain with 
respective Aid Stations during combat. 

(3) Medical personnel will take same 
precautions regarding concealment, camouflage, 
and local security as combat troops. 

b. Handling Casualties: 

(1) Attach medical emergency tag to 
all casualties when first treated. Fill in name, 
organization, nature of luound^ and treatment 

(2) Battalion, Regimental, and Shore 
Party Medical Section will log all casualties 
passing through, showing name, organization, 
nature of ivound, injury or sickness, and dispo- 

(3) Shore Party Medical Section will 
classify wounded in accordance with method 
of transportation and expected recovery. 

(a) Ambulatory. 
(6) Litter. 

(c) Nontransportables. 

(d) Patients who will become effec- 
tives in 10 days will not be evacuated. 

(d) Casualty reports will be made 
through normal channels to Division. 

c. Chain of Evacuation: 

(1) Through Battalion Aid Station via 
Regimental Aid Station to beach, to APA 
or hospital. 

d. Exchange of Supplies: 

(1) Particular attention will be given 
to exchange of litters, splints, dressings, and 
plasma between Battalion and Regimental Aid 
Stations, Shore Party Medical Section, and 
ship or hospitals. 

e. Disposition of Dead: 

(1) All dead will be tagged, collected 
at Battalion Aid Station, and disposed of as 

(2) The Graves Registration Section, 
plus 2 dental technicians from Combat Team 

will function under direct control of the Chap- 
lains. Two Form '*N'' will be prepared, and 
in the case of dead who cannot be definitely 
identified otherwise. Form NMS H-4 (Dental 
Chart) will be prepared and securely attached 
to original certificate of death. 


a. Individual: 

(1) Medical Officer Unit One 

(2) Dental Officer Unit Two 

(3) Corpsmen (Medical) . Unit Three 

(4) Corpsmen (Dental) . . Unit Four 

b. Battalion Aid (Infantry) : 

(1) Two Jeep ambulances. 

(2) Units 1 to 5 inclusive, 3 each of 
units 6 and 7, 4 unit-9, 1 unit-10. 

(3) Sick call chest. 

(4) Bulk supplies (packed in water- 

proof pouches) : 

(a) Battle dressings, 
large 100 

(b) Battle dressings, 
small 500 

(c) Benzedrine 1,000 tablets 

(d) Morphine syrettes, 
packet 50 

(e) Plasma 60 units 

(/) Plastic leg splints 12 

(Battalion Aid Station will be divided three 
ways and loaded in landing craft.) 

c. Regimental Aid (Infantry) : 

(1) Same as Battalion Aid (Infantry). 

d. Artillery Regiment: H&S and Artillery 

(1) Same as Battalion Aid (Infantry) 
less 1 Jeep ambulance and 10 canvas litters. 

e. Special and Service Troops: 

(1) Same as Battalion Aid (Infantry) 
less Jeep ambulance. Twelve folding litters in 
place of canvas litters. 

f. Collecting Section (Medical Company) : 

(1) Same as Battalion Aid (Infantry) 
less 1 Jeep ambulance and sick call chest. 
Twelve folding litters in place of canvas litters. 



(2) Additional Aid Station Equipment — 
120 units of plasma, 5 expeditionary cans, 1 
lister bag, and 1 utility box. 

(3) 20 percent bulk supplies of Medical 

g. Medical Company (less three collecting 

sections) : 

(1) Initial Group: 

(a) 1 Jeep ambulance, combat 


( 6) Two 4 by 4 one-ton trucks, combat 


(c) 2 field ambulances, combat 


(d) 1 trailer, water. 

^ This equipment will include portable svirgei-y with necessary- 
instruments and sterile packs to enable them t(» perform ab- 
dominal surgery within first 24 hours; 50 stretchers, 50 blankets, 
50 cots, and four tarpaulins. 

(e) 1 one-ton trailer, cargo. 

(2) Secondary Group : 

(a) Remainder of equipment and 
plies of 72-bed hospital included in 

(8) 40 percent bulk supplies of Bj 


h. Medical Battalion (less 3 Medical Con^. 
panics) : 

(1) H&S Company: ■ 

(a) 1 Jeep. f 

(b) Officer equipment. ¥ 

(2) Two Companies (Medical) : 

(a) Supplies and equipment for t\vo 
Medical Companies. When additional Medici] 
Company is assigned to Infantry, Regimental, 
or Artillery Regiment, their supplies and equip, 
ment will be divided as Medical Compani^ 
normally with Infantry Regiments. 

Chapter VI 

Medical Service With Amphibious Forces 
in the Saipon Operation 

Eugene R. Hering, Captain (MC) USN 

During the amphibious avssaults on Japanese 
strongholds in the Pacific from Guadalcanal 
to Okinawa, the United States Marines suffered 
approximately 95,000 battle casualties. The 
thousands of wounded in the first few days 
of the assaults on Tarawa, Guam, Peleliu, 
Saipan, Tinian, and Iwo Jima would have 
taxed the efforts of even a dozen well-equipped 
major hospitals. To provide every phase of 
medical attention, from initial first aid to defin- 
itive treatment, w^as the mission of the medical 
service of the Amphibious Forces in the Pa- 
cific. In addition it was necessary to maintain 
the health of the 300,000 troops who were often 
encamped in disease-infested areas. Instituting 
preventive medicine measures, supervising 
sanitation, weeding out the physically unfit, 
training medical officers and corpsmen, and 
welding these personnel into a smoothly func- 
tioning organization, were some of the prob- 
lems facing the Field Medical Service of the 
Navy Medical Corps. The Medical Department 
of the forces afloat who closely supported the 
Landing Force also had similar, almost over- 
whelming, tasks to perform. 

The initial planning for field medical service 
was done by a handful of medical officers who 
by long association with the Marine Corps 
foresaw the need for building up of this special- 
ized branch of the Navy Medical Corps. No 
training school existed for this particular func- 
tion of the Medical Department and only a few 
officers had availed themselves of the opportun- 
ity to attend the Army School of Field Medicine 
at Carlisle, Pa. As a result, all through the war 
there was a lack of medical officers well versed 
in staff administrative work and the tactical 

employment of medical troops in the field, to 
administer the large force that eventually was 
on duty with the Marine Forces in the Pacific. 

The modernization of equipment and the pro- 
mulgation of new doctrines appears to have 
been based on local decisions rather than on 
directives emanating from the Bureau of Medi- 
cine and Surgery, perhaps because there was no 
department in the Bureau dealing exclusively 
with Field Medicine. It was not until late 
1942 that liaison between the Bureau and the 
Headquarters Marine Corps was established; 
in fact a full fledged amphibious medical service 
was not created until 1946. 

This slow development of the Medical Service 
shows the need for continuous medical pre- 
paredness in times of peace. Our modern 
Amphibious Forces actually came into being 
with the inception of the Fleet Marine Force. 
There had been landing maneuvers prior to 
this time and much study of the problems of 
landing an attack force had been undertaken 
by Marine Corps Schools, but the formation 
of the Fleet Marine Force served to crystallize 
the aims of the medical components and gave 
to this specialty in military medicine the status 
it deserved. The Navy doctrine for landing 
operations, first conceived in 1934, was devel- 
oped in the maneuvers in 1935, 1936, and 1937, 
which revealed the immense problems involved 
and indicated a solution for some. The Landing 
Operations Doctrine then evolved was logical 
and sound for the size of the units involved. It 
was then realized that extensive medical sup- 
port was needed, for the reports of those man- 
euvers were unanimous in their recommenda- 
tion for the assignment of more medical per- 



sonnel. This is understandable when one reads 
that the hospital section of a provisional medical 

company in the brigade maneuvers on Culebra 
in 1939 consisted of one medical officer and 
six hospital corpsmen. 

Early in 1940 two medical companies were 
formed. As they were rather an orphaned outfit, 
with no one to look after their pay, messing, 
accountability^ and zone of operation, a head- 
quarters and service company was authorized 
soon after and the brigade surgeon was given 
additional duty as commanding officer of what 
was then designated the Brigade Medical Bat- 
talion. Two more companies were added later 
the same year and when the division was formed 
a fifth company came into being to give more 
medical support. This then was the sum total of 
our Medical Field Service at the start of the 

Following experiences at Guadalcanal, and 
with the formation of more marine divisions, 
the need for additional medical support became 
apparent. An independent medical battalion of 
five medical companies was formed and sent to 
the South Pacific as reserves to give medical 
support where most needed. These companies 
never functioned efiiciently in that capacity 
because of the tactical situation which pre- 
vailed. Eventually the battalion was reduced 
to three companies plus a headquarters section 
and became the Corps Medical Battalion> em- 
ployed as an echelon of medical support in the 
rear of the division. 

As the scope of operations progressed and 
forces of almost Army dimensions were acti- 
vated, the medical needs increased proportion- 
ately. To meet this need, three corps evacua- 
tion hospitals were oi'ganized and trained, the 
first one being ready in time for the Iwo Jima 

During the final operation of the war in the 
Pacific, the medical support of the two divisions 
engaged consisted of the organic medical sec- 
tions of battalions, regiments, and separate 
battalions, the organic medical battalions of 
each division, one corps medical battalion, and 
two corps evacuation hospitals. 

On V-J Day approximately 700 medical 
officers, 230 dental officers, 90 Hospital Corps 
officers, and 10,000 hospital corpsmen were on 

duty with the Marines in the Pacific theateK 
This was a far cry from the handful of medi^^ 
personnel available to Capt. Warrick T. Brow 
(MC) USN, on the 1939 maneuvers. 

The responsibility of the medical service oj 
the forces afloat was well stated in the doctrine 
of 1938. The need for hospital ships ^^ 
especially fitted casualty carriers was clearly 
shown and their use was outlined. That mot^ 
of these ships were not available at the start 
of the war and that the few available were 
initially not better fitted into the tactical piau^ 
of the forces afloat is not surprising, in vie\f 
of the uniform lack of all types of service 
vessels in the Navy at that time. Although the 
need for specially built assault transports had 
been apparent for some time, it was not until 
1941 that such ships were actually in opera, 
tion. One concept that greatly affected our 
medical planning was the doctrine, enunciated 
in the Transport Doctrine of the Amphibious 
Forces of the Pacific Fleet, that an assault 
transport could care for 150 litter cases and up 
to 325 ambulatory wounded. This doctrine was 
probably bom of necessity, because of the lack 
of hospital ships and casualty carriers, but it 
was a dangerous concept and wholly incon- 
sistent with adequate care of casualties. It 
was part of a pattern of thought which per- 
meated the forces afloat and influenced the 
establishment of hospital facilities ashore. It 
was the **bed for a casualty" type of thinking; 
in other words, as long as the wounded man was 
in a bunk and out of sight of the troops, part of 
the medical mission was accomplished. It must 
be recognized that war wounds are surgical 
problems, best handled by a trained surgeon 
during the golden hours of early surgery. When 
one considers the facilities and personnel re- 
quired to care for 150 seriously wounded 
patients, as well as for 325 patients with minor 
wounds, it becomes apparent that 3 medica 
officers with limited equipment, regardless of 
their talent or heroic efforts, will not suffice. 

Early in the war, our forces did not enjoy 
the mastery of the sea and air which character- 
ized the later amphibious operations. Trans- 
ports were forced to retire to the open sea in 
the late afternoon to insure space for maneuv- 
ering to avoid air and submarine attacks ; they 



Id not return to the transport area until an 

after daylight. This was the weakest link 
^^oiir evacuation chain and medical service. On 

hotly contested beachhead it was impossible 
ggtablish surgical installations ashore until 
1 day-pl^S'2 or 3, and with no ships available 
1 the evacuation of patients at night those 

sualties that occurred in the late afternoon or 
tiring the hours of darkness often spent many 
hours the beach or in open boats, before 
reaching facilities that could provide definitive 

Hospital ships and ships fitted as casualty 
carriers (APH's) were not available in suffi- 
cient numbers to cover the entire theater of 
operations, and because of the dangers of enemy 
attacks, they were used cautiously. At Tarawa 
thev were kept about 80 miles away and did 
not anchor to take on casualties until the 
operation was completed. One hospital ship 
took approximately 265 casualties from the 
transports and the other did not receive a pa- 
tient. At Saipan no hospital ship was available 
until the third day, and thereafter only at 
irregular intervals. In the final operation at 
Okinawa 2 hospital ships and 2 casualty car- 
riers were present at all times. It is ironic 
that the only hospital ship to suffer major 
damage and casualties was steaming away from 
the scene of combat fully lighted, while those 
that were lying in close support, just off the 
landing beaches and within the protecting ring 
of our pickets and transport area defenses, 
suffered no damage. 

The use of LST's for casualty handling and 
distribution was developed relatively early in 
the South Pacific campaigns. Designated LST 
(H)'s, and staffed with surgical teams from 
rear echelons for each operation, these ships 
became an important link in the chain of evac- 
uation. One LST (H), the 46'4, was completely 
refitted as a hospital ship to give close support 
off the beach. She proved ideal for giving early 
definitive care when further evacuation could 
not be accomplished. In the Central Pacific 
campaigns, until the Iwo Jima and Okinawa 
operations, there was a lack of this type of 
vessel ; 6 had been lost by explosion of ammu- 
nition just prior to the Saipan campaign, neces- 
sitating a complete revision of plans. 

At Iwo Jima, one LST employed as an LST 
(H) received and distributed almost 2,600 
casualties. Okinawa saw the employment of 
these ships in sufficient number and with ade- 
quate staff and equipment to carry out their 
mission. Plans for later operations called for 
even greater use of these craft for casualty 

One of the greatest burdens placed on the 
Field Medicine Department was the supervi- 
sion of sanitation and the institution of preven- 
tive medicine measures. Although the staff 
manuals and operation orders maintain that 
measures for the prevention of disease are a 
command function, too often the tremendous 
importance of this administrative phase of a 
military operation was overlooked. As a result, 
the record of our fight against tropical disease 
was not an outstanding one. 

There are many reasons for the failures in 
this field. Medical Intelligence was for the most 
part entirely lacking or so distorted that no 
accurate picture of the diseases prevalent in 
an area was available. Initially it was actually 
believed in certain commands that white men 
could not contract filariasis. The intensity of 
malai'ial infection was underestimated. Very 
little information was available regarding 
scrub tjrphus. In the later campaigns the pen- 
dulum swung completely over, and on the last 
operation, Okinawa, the troops were fully pre- 
pared for any diseases and health hazards that 
might exist. 

When it became apparent that disease was 
taking a far greater toll than Japanese bullets, 
specially trained malarial and epidemiological 
control units were organized and assigned to 
marine divisions. These organizations were of 
inestimable value in that they provided well- 
trained personnel whose sole function was in 
the field of preventive medicine. The entire 
program fell short of fulfillment, however, be- 
cause there were no labor details to carry out 
the recommendations of these units. A sufficient 
number of trained and equipped personnel were 
never available to carry out preventive medi- 
cine measures on a large scale. Regardless of 
the indoctrination and discipline of combat 
troops, they are incapable of doing both the 
fighting and the necessary house cleaning. 



Eventually details of 50 men from the Seabees 
were assigned the mission of carrying out 
disease prevention measures for each division. 
This arrangrement was still inadequate, for these 
personnel were never available for sufficient 
training. Their prime mission was the building 
of roads and airports, so that their use for 
sanitation and disease control was limited. 

The answer to disease control on a large 
scale is the formation of a trained and equipped 
unit actinp: directly under control of a section 
of the Medical Department whose primary mis- 
sion is sanitation and epidemic control. With 
the threat of bacteriological and atomic warfare 
and the need for trained personnel for decon- 
tamination, such a unit assumes added import- 

The Saipan operation, as the midphase of 
the offensive against the Japanese, lends itself 
well to a portrayal of amphibious medical serv- 
ice, afloat and ashore. There was both furious 
resistance on the beachhead reminiscent of 
Taraw^a and prolonged fighting over rugged ter- 
rain that gave the Medical Department an 
opportunity to establish itself fully ashore and 
assume its vital role. 

It is well to emphasize that in the assault on 
Saipan the Medical Department personnel had 
many advantages over those engaged in the 
earlier campaigns. First, there were more ships, 
planes, men, and supplies ; and relative mastery 
of the sea and air was ours. Second, malaria 
and the rigors of a tropical climate were absent. 
Third, there w^ere honest and forthright reports, 
both written and verbal, of preceding opera- 
tions, pointing out mistakes and making recom- 
mendations for their correction. Fourth, 50 
percent or more of the medical officers and 
hospital corpsmen had been in combat and 
therefore knew the demands to be made upon 
them. Fifth, the outfit, by bitter experience in 
battle, appreciated the Medical Department and 
spared no effort to provide the medical unit 
with assistance in training, planning, and intel- 
ligence concerning the coming operation. 

The most important phases of an operation 
is the training period preceding it. It is during 
this period that the lessons learned in previous 
combat are evaluated and translated into oper- 
ating doctrine while the replacements for those 

lost in previous combat are welded into a 
that will act with automatic precision i^ 
face of whatever hazards are encountered. 

The training period officially began 
January 1944 on the broad high plateau of tJJ 
northern end of the "Big Island,'' Haw^ 
Battalion, regimental, and separate battaM 
medical sections, besides carrying on the routjjjj 
sickbay activities, closely participated in ^ 
of their organization's field problems. The 
ical companies, for the first time, were biy. 
ouacked together under the administration o{ 
headquarters company of the medical battalion. 
These companies were rotated through three 
types of training. An Army hospital on the 
outskirts of the bivouac area provided hospj. 
talization for our sick. Two medical companies 
and various specialists from other companies 
served on the staff. This allowed for 
training of technicians and kept professiona" 
interest alive. A field hospital in the bivouac 
area, which was staffed by 2 medical companies, 
gave both medical officers and corpsmen 
chance to thoroughly familiarize themselves 
with the equipment they were to work with in 
the field. The third type of training consisted of 
participation in field problems for 1 month and 
establishment of the medical company instal- 
lation in a variety of locations and situations. 

Classes were held throughout the division for 
basic training in plasma administration, record 
and supply w^ork, blackout precautions, evacua- 
tion of tanks, loading of DUKW's and arnph- 
tracs with simulated casualties, and many other 
details. Every medical officer and corpsman in 
the division was given training in the care and 
firing of small arms. Most of the company aid 
men on their own initiative mastered all of 
the various weapons carried by the Marines of 
their platoons, including the 50-caliber machine 
gun ; bazooka, 37 mm. gun ; and light mortar. 

As a forerunner to actual planning, com- 
ments from all medical officers w^ho participated 
in the Tarawa operation were secured and eval- 
uated. Amphibious warfare is an ever-develop- 
ing science and comments on any previous oper 
ations were considered, not in the light o 
mistakes that occurred, but rather in regard 
to the lessons learned. Several elements of doc- 
trine regarding supplies, equipment, and tac- 




employment were evolved from these 


Experience had shown that the field units, as 
sued, were of little value for battalion and 
^.egimental use. On the way into the beaches 
\l Tarawa, many corpsmen had been hit and 
their equipment lost with them. Thus if a corps- 
man detailed to carry in 'T^nit X'^ was lost, 
there was a shortage of battle dressings ; if the 
men detailed to bring in the boxes of plasma 
became casualties, there was a shortapre of 
phisma. The equipment and supplies as issued 
were individualized too much. To offset this, 
assault medical packs made from the canvas 
carrying case and filled with such vital items 
as battle dressings, plasma, morphine, and sulfa 
drugs were prepared in identical loads for all 
units of the division. These assault packs, plus 
litters and plywood splints, were the sole initial 
allowance of the battalion aid sections. Further, 
the jeep ambulance was loaded with splints, 
litters, blankets, extra plasma, and a compact 
sick call chest. 

For immediate resupply, one amphibian 
tractor stationed off each regimental beach was 
assigned to the Medical Department and carried 
a full load of litters, blankets, and splints, as 
well as resupply units in 50-pound cases, con- 
taining plasma, battle dressings, morphine, and 
sulfa drugs. These amphibian tractors were to 
lie aloii.irside the logistical control boat and be 
available to any section of the regimental 
beach on call. 

Vehicles were combat loaded with medical 
company equipment in such a manner that 
when landed they could proceed at once to 
their designated location inland and set up a 
surgical installation. The rest of the supplies 
and equipment, sufficient for 30 days, was to 
come ashore when general unloading started. 

Because heavy casualties were expected on 
the beachhead, collecting sections were equipped 
and personnel trained to function in the same 
capacity as battalion aid stations. Also, because 
it was believed that the regimental commanders 
^ould be so involved in the heavy fighting as 

prevent them from assuming responsibility 
^or the assigned medical companies, the medical 
plan called for all companies to come under 

258015- 53 13 

division control once the transport areas were 
reached, and to land on division order only. 

One glaring error in the planning was over- 
looking the problem of civilian casualties. 
Previous operations had been on sparsely 
settled atolls or islands, where the problem of 
handling large scale civilian casualties did not 
arise, but early in this campaign it fell to the 
division medical service to provide humani- 
tarian care for civilians at a time when the 
medical personnel were already taxed to the 
utmost in caring for the wounded. 

On Hawaii the morale of the troops was never 
higher. Good food, a healthy climate, and 5 
months of hard training had molded them into 
a confident, poised unit. Embarkation of med- 
ical personnel and equipment started the first 
w^eek in April 1944 and proceeded smoothly, 
due mostly to the direction of the medical offi- 
cers who had attended the transport loading 
school. As dock space allowed only one regimen- 
tal combat team to load at a time, there w^as a 
continuous flow^ of equipment and supplies from 
our encampment at Camp Tarawa down to the 
docks at Hilo, 60 miles away. A chart showing 
the location of all medical supplies and equip- 
ment aboard the various transports was in- 
cluded in the administrative order. Medical 
personnel of the assault waves were loaded and 
with their respective troops and medical com- 
panies were distributed among 5 transports to 
reinforce them initially for casualty handling. 
The over-strength allowance of medical officers 
was distributed among the LST's having no 
medical officers aboard to take care of troops 
en route. 

D-day for the Saipan operation was 15 June 
1944. Long before that time our naval gunfire 
and bombing had been crashing into the beach- 
head and selected inland targets, until it was 
difficult to believe that anything could live in 
that area. This same impression had been rudely 
shattered at Tarawa, however, and every glass 
available was trained on the beachhead by those 
not in the assault, as the leading amphibian 
tractors left the line of departure and wallowed 
in toward the reef. There followed breathless 
moments as they came closer and closer, then 
geysers of water could be seen in and around 




the first vehicles and all illusions of an easy 
landing were gone. 

The first casualties reached the transports 
at 1015 and from then on almost every return- 
ing boat brought its load of wounded. The two 
Marine divisions that landed abreast that day 
suffered 1,750 casualties before the next morn- 
ing. What was occurring ashore could be sur- 
mised in part from the reports of the individual 
battalion surgeons. Much, however, must be 
read between the lines as the heroic sacrifices 
that characterized the performance of the 
troops and medical units alike is imperfectly 
brought out in the documents of battle. 

The Sixth and Eighth Regiments landed 
abreast with two battalions of each regiment 
in the initial assault. Company aid men went 
ashore with their respective platoons, whether 
in the first wave or the succeeding ones. The 
battalion aid sections landed uniformly in the 
fourth and fifth weaves. Collecting sections were 
scheduled to land in the first waves of the 
second trip of the amphibian tractors, and 
landed at approximately H-plus-90-minutes. 

Excerpts from the records relate the high- 
lights of the first few days. From the Second 
Battalion, Sixth Marines: **Medical section 
landed in the fourth and fifth waves on Red 
Beach at H-plus-21-minutes. The battalion sur- 
geon was hit by a mortar shell in the first 10 
minutes. The aid station was set up on the 
beach and wounded treated where they fell and 
evacuated in amphibian tractors. Bandsmen 
attached as litter bearers did a magnificent job. 
SupiDlies were adequate with the exception of 
litters. Two hospital corpsmen were killed and 
10 wounded during the first 24 hours. Phar- 
macist's Mate Third Class Robbins was killed 
on D-night while manning a machine gun in 
his company.'' 

From the Third Battalion, Sixth Marines: 
^'Corpsmen with I Company landed in the first 
wave at 0830, corpsmen with K and L compa- 
nies landed in the second and third waves, 
respectively. The battalion aid section landed 
at H-plus-20-minutes and set up in Japanese 
trenches on the beach. Forced to move, as artil- 
lery made direct hit on an amphibious tractor, 
setting it afire and making the position un- 
tenable. At 1500 moved inland about 200 yards 

and set up in Japanese dugout near battali 


command post. A shortage of litters < 

wounded were evacuated in ponchos. 

corpsmen were killed in action and ei&K^^ 
wounded the first day. On the morning of j) 
day-plus-2, the battalion bore the brunt of 
Nip tank attack, knocking out 29 enemy t?ix\]^ 
One corpsman was killed and three woun^g^ 
during this encounter." 

The Second and Third battalions of 
Eighth Regiment landed almost 1,000 yards to 
the north of their intended area. When Eighth 
Regimental Headquarters landed at H-plus-BO. 
minutes, the entire section including the regi. 
mental aid group landed on a beach with no 
troops in front of them. Casualties were ex- 
tremely heavy and the regimental medical sec- 
tion functioned in the capacity of a battalion 
aid station until the two assault battalions 
could be maneuvered into their proper position. 
The medical section of the Second Battalion of 
the Eighth Regiment suffered heavy casualties 
when an artillery shell landed in the aid station, 
killing one corpsman and seriously wounding 
the battalion surgeon and three corpsmen. 

Because of the heavy casualties in the imme- 
diate beach area, the collecting sections assigned 
to the assault battalions served both as aid 
stations and evacuation stations for the first 2 
days. Shore party medical sections and Navy 
Beach Party medical sections were committed 
uniformly on D-day-plus-1. When these sections 
assumed the evacuation station responsibility, 
collection sections moved forward to work in 
close conjunction with battalion aid stations. 
They were returned to their respective medical 
companies on about the sixth day, by which 
time adequate ambulance transportation was 
available almost to the frontlines. 

Meanwhile, the medical companies on the 
transports were working unceasingly to assist 
the ships' medical departments in the care of 
casualties. Enemy fire on the beaches was so 
intense that it was impracticable to land and 
establish medical facilities ashore. On D-day- 
plus-1 reconnaissance revealed a Japanese 
civilian hospital in the Charan Konoa area on 
the right flank of the division, miraculously 
unscathed by our preinvasion bombardment- 
As evacuation at night was highly unsatisfac- 



due fo smoke screens laid to protect the 

. f j^om enemy air attack, C and E Medical 
r mpanies were ordered ashore at 1200 on 
p day-pl^S"^ in order to provide some measure 
of definitive treatment to casualties during the 
hours of darkness. E Medical Company landed 
at 1700 but was forced to dig in immediately 
because of heavy enemy shelling. C Medical 
Company landed at 0730 on D-day-plus-2 and 
the two companies proceeded to the Japanese 
hospital and were in a position to perform 
surgical operations by nightfall. 

On D-day-plus-5, E Medical Company was 
moved to the north to the junction of the major 
road network to act as a screening agency for 
all casualties, as w^ell as to provide a surgical 
unit nearer the center of the zone of action, for 
treatment of nonevacuables. It was replaced 
at the Charan Konoa by a tine surgical team 
from the Army. 

No records are available for the first 2 days 
of the casualties received at the Charan Konoa 
installation, but in the next 7 days, 898 casual- 
ties were admitted and 46 major surgical pro- 
cedures were performed. If one remembers that 

only casualties that could not be evacuated to 

ships at night were handled here, the immense 
importance of the early establishment of this 
hospital is more fully realized. 

A summary of the chain of evacuation at this 
stage follows (tig. 154). Initially, the nearest 
medical personnel put casualties in any am- 
phibian tractors available. Aid stations and 
collecting sections established evacuation 
points on landing, and on D-day-plus-1 evac- 
uation was consolidated through shore party 
medical sections. Regimental medical sections 
began to channel casualties through their instal- 
lation on D-day-plus-2. Beginning on the even- 
ing of D-day-plus-2, all casualties occurring 
late in the evening or at night were evacuated 
to the medical companies at Charan Konoa. 
With the establishment of E Medical Company 
at the major road junction, all casualties, both 
day and night, were channeled through this 
installation. In daylight all casualties capable 
of being further evacuated were sent to ships, 
and at night were either retained at E Medical 
Company or sent to C Medical Company in 
Charan Konoa. 

Figure 154. — One chain of evacuation of the wounded. 



Casualty evacuation from the beach was 

undertaken in amphibian tractors, any tractor 
leaving the beach being utilized. The original 
plan called for one LST(H) off each division 
beachhead, to act as a casualty clearing station 
to insure reasonable distribution of casualties 
among the transports. Owing to changes in 
the designation of the vessels assigned to this 
task, the plan was not carried out and casual- 
ties were transferred to any LCVP available 
at the tractor transfer line. The LST (H) 
assigned to the Second Marine Division beach- 
head received its first 100 casualties while still 
in the transport area, 22,000 yards from the 
beach. When the 100 casualty mark had been 
reached, this LST (H) came alongside the 
U. S. S. Monrovia and discharged all the casual- 
ties to that ship. As there were no hospital 
ships or other especially fitted vessels for 
casualty handling, the transports were the sole 
agency to care for the tremendous load of 
casualties which occurred the first 3 days. 

Although the medical officers and corpsmen 
worked unceasingly, an analysis of the battle 
casualties in immediate need of definitive care 
as compared with facilities available shows the 
overwhelming demands on the Medical Depart- 
ment afloat. Of the 1,750 casualties which oc- 
curred the first day, an esliiftated 20 percent or 
350 were either killed outright or beyond 
medical assistance. Forty percent or 700 were 
slightly wounded and not in need of immediate 
definitive treatment. The remaining 40 percent 
or 700 required immediate treatment. Approxi- 
mately 40 transports were in the area, available 
for casualty handling. This meant that even 
if an absolutely equal distribution of patients 
could have been made, each transport would 
have had 17 to 18 casualties demanding imme- 
diate treatment in the first 20 hours and the 
expectation of as many more for the next 2 or 
3 ddys. Actually, with no distribution agency 
functioning, several of the APA's bore the 
brunt of the casualty load. Evacuation to the 
ships at night was extremely difficulty if not 
impossible in most cases, due to the smoke 
screen that fogged the transport area during 
air alerts. 

On D-day-plus-3 the first hospital ship arrived 
and was immediately loaded with the casualties 

that had accumulated. As our transports wej. 
forced to leave the area on D-day-plus-2 becau^^ 
of threatened Japanese surface attacks, casuj^j^ 
ties from the Second Marine Division \ver^ 
channeled to APA's supporting other organi. 
zations, increasing the demands on already 
overloaded ships. 

The Medical Department's participation 
this operation can be divided into two phases. 
Due to the withdrawal of our transports, the 
division was unable to land much of 
vital supplies, ammunition, and three of the 
medical companies. These medical companies 
had not been ordered ashore until noon of B, 
day-plus-2, as the tactical situation ashore 
would not permit their utilization. By the time 
the order to land reached them, it was too late 
for them to disembark and they accompanied 
the transports to sea, assisting in the care of 
the casualties already aboard. From a military 
standpoint, the division was reduced to improv- 
ing its local position until the transports re- 
turned and supplies could be built up for the 
further occupation of the island. 

During the first phase, from D-day until 
D-day-plus-6, the policy was for immediate 
evacuation, except for nonevacuables. Those 
patients who required it were given immediate 
definitive care during the hours when evacua- 
tion to ships was impossible. The second phase ; 
began with the establishment of the division 
hospital ashore on D-day-plus-7, at which time 
the extent of definitive care given to all casual- 
ties was governed by the capacity of the hos- 
pital and the speed of evacuation to supporting 
hospital units ashore or afloat. 

Immediately on the return of the transports 
to the transport area off the Division Beach, D 
Medical Company and the division hospital 
consisting of A and B Medical Companies, 
were landed. All three medical companies moved 
directly to the group of damaged buildings that 
had formerly housed the main Japanese radio 
installation. Although filled with debris and 
partially smashed by our preinvasion bombard- 
ment, these buildings could accommodate 301 
patients and offered housing for a hospita 
installation which is seldom available in battle 
They were strategically located near the major 
road network, both to the frontlines and to 


^l^e beach evacuation station. Built of reinforced 

concrete and surrounded by 15 feet of earth- 
;vorks, they offered a large measure of protec- 
tion fYom direct fire and from light artillery 
and bombs. With the able assistance of working 
details from the Seabees and engineers, debris 
and damaged machinery were quickly cleared, 
overhead and bulkheads were repaired, and an 
operating room with 6 operating tables was 
set up. On the night of D-day-plus-7, 37 casual- 
ties were treated, on the second day 58, and on 
the third day 159. As more space was cleared, 
additional operating units were set up. Three 
surgical huts were used as clean operating 
rooms. Deep trenches dug by bulldozers offered 
protection for the patients in case of air raid. 

On D-day-plus-11, C Medical Company was 
moved to this installation. Although the total 
bed capacity of 4 medical companies is set at 
576 beds, by pooling our facilities, this re- 
inforced division hospital was able to accom- 
modate almost twice that number of sick and 
wounded. In the majority of instances, to main- 
tain a casualty census of this size in the divi- 
sion zone of action would not be good practice. 
The division had another operation to under- 
take, however, immediately following the Sai- 
pan campaign, and the guiding principle was 
to retain every patient who could be readied 
for this second assault. 

During the campaign, 3,612 of the 5,156 
patients admitted to the medical companies 
were returned to duty in tim^ for the Tinian 
operation which began 2 weeks after Saipan 
was secured. 

A good road network fanned out to all front- 
line units, and although the distance to the 
front increased to as much as 5 miles before 
the battle ended the many advantages of the 
initial installation outweighed the disadvan- 
tage of the longer ambulance haul. Evacuation 
seaward was easily accomplished with the use 
of DUKW's loading directly at the hospital and 
necessitating no transfer of personnel before 
they arrived aboard ship. Although the front- 
lines were at times less than a mile forward 
^nd artillery and mortar fire occasionally fell 
in the area, no casualties were sustained from 
^nemy fire. Snipers were active in swamps 
^I'ound Lake Susseppe, 400 yards to the east. 

but were cleared out by the division reconnais- 
sance company after several days. 

Under the direction of the medical battalion 
commander, the 4 medical companies were 
molded into an evacuation hospital. A central 
admission and triage ward was set up which 
distributed casualties according to type to the 
various surgical teams set up for each specialty. 
C Medical Company set up 400 beds to accom- 
modate the acutely ill, mostly dysentery, 
dengue, and recurrent malaria. E Medical 
Company admitted patients with chest and eye 
injuries and A and B Medical Companies took 
the orthopedic and abdominal cases. Those 
with minor injuries were distributed among all 
four companies, depending on the bed capacity 
at the moment. 

Centralization of the service elements of the 
four companies relieved the medical officers of 
a great many of the details of administration. 
Supply, messing, guard detail, transportation, 
and sanitation were all handled by Headquar- 
ters and Service Company of the battalion. The 
direction of the combined mess by a dental 
officer was especially notew^orthy. He procured 
fresh food from the transports daily and with 
the aid of 15 Negro messmen from division 
headquarters, served 1,200 hot meals 3 times a 
day. A damaged frame building to the rear of 
the main hospital, w^hich was screened, pro- 
vided a completely flyproof galley, and the hot 
meals thus available on D-day-plus-9 undoubt- 
edly played a large part in the early return to 
duty of many patients. 

During this period, we had three cardinal aims : 
(a) Hospitalization of those who would 

return to duty within 30 days. 
(6) Hospitalization and treatment of non- 
evacuables, until their condition im- 
proved sufficiently to allow their safe 
evacuation by air or to hospital ships. 
(c) Definitive treatment of those for whom 
earliest possible care w^as necessary to 
give them the best chance of recovery. 

The statistical report of the Second Marine 
Division Hospital, as presented in table 24, 
analyzed 2,088 cases of battle injuries and 2,466 
cases of disease, combat fatigue, and nonbattle 


Table 24. — Statistical report — Second Marine Division hospital 

Type of injury 




















Chest (intrathoracic) 

















Chest and abdomen 










Spinal cord 










Extremities. _ _ 


17 3 

















' 27 

Abdomen and extremities — 










Chest and extremities. _ 


















Chest, spine, and abdominal 










Shrapnel, multiple 










Miscellaneous, wounded. _ 










Disease, combat fatigue, and non- 
battle casualties — 











1 4,554 









1 There is a discrepancy of 204 between total admissions from the daily admission records and the report of admissions, beca^,, 
many marines with minor wounds came in for treatment and then without authorization left the hospital to get back to their organi^; 
tions on the frontlines before their case records wei-e completed. 

Note: No record was kept of the number of local anesthesia employed. Local anesthesia was used in all debridements whei« i 
general anesthesia was not employed. 

In this series, 124 casts were applied and 15 
amputations performed. Of 41 patients with 
abdominal wounds, 21 were operated upon, the 
mortality rate being 28 percent. Of the re- 
mainder, some were evacuated immediately to 
a hospital ship. 

The importance of the presence of an oph- 
thalmologist is demonstrated by the following : 
Of 112 patients with eye injuries, 53 were 
carried under some other diagnosis because the 
eye injury was secondary. Twenty-two patients 
required immediate major surgical treatment 
for (a) penetrating injuries of the cornea with 
foreign bodies in the iris, (ft) destructive 
injuries to lids and orbital tissue involving 
extraocular muscles and adjacent structures 
that required debridement or control of hemor- 
rhage, (c) penetrating wounds of the sclera 
requiring suturing to prevent lost of vitreous, 
and (d) enucleation of remnants of the eyeball. 
Eighteen patients with retinal detachment were 
received. These were diagnosed only because 
an experienced ophthalmologist was available. 
Five patients had intraocular foreign bodies 
visible with an ophthalmoscope and 18 had 
intraocular foreign bodies demonstrable by 
roentgenogram. Thirty patients had severe 
corneal injuries and embedded foreign bodies. 
Twenty-nine patients had serious eye lesions 
associated with burn or face injury. 

Pooling of medical companies cannot be done 
where long lines of evacuation exist or where 

the road network does not converge. The effec- 
tiveness of these units, however, was the basl^ 
for the reorganization of the medical battalion. 
Medical companies supporting the regiments 
were permitted to have a maximum of 60 beds 
and the majority of the medical services of the 
division were concentrated in 2 hospital com- 
panies where all the specialties were repre- 

While the attack was being pressed, medical 
officers and corpsmen in the frontlines, without 
exception, bore up under the ordeal and added 
heroic chapters to the fine record of the Field 
Medical Service. The battalion medical section 
of the First Battalion, Twenty-ninth Regiment 
suffered 27 battle casualties out of a comple- 
ment of 40. Both medical officers were wounded, 
yet despite their wounds they remained on duty 
for hours until relieved. Three Navy Crosses 
were awarded to members of the section for 
that day's work — two posthumously. 

The final massive amphibious assault of the 
war in the Pacific, at Okinawa, demonstrated 
the rapid strides that were being made in the 
handling of casualties. Although they were not 
put to the test initially, due to the almost unop- 
posed landing, the facilities available afloa*. 
reflected the planning and thought given to 
phase of the operation and undoubtedly ^voulc 
have been sufficient to handle the casualtie-' 
from a furious beachhead resistance. In 
trast to the operation at Saipan, 9 mon- 


•eviousl.v. 2 LST(H)'s and a total of 8 ships 
^!ell-stafFed, equipped, and trained in their 
mission were in operation shortly after H-hour 
1 000 yards off each division beachhead. At least 
two hospital ships were on hand at all times. 
Several casualty carriers (APH's) were avail- 
able in the transport area to care for naval and 
landing force casualties, and APA's reinforced 
initially by medical personnel of supporting 
corps evacuation hospitals and surgical teams, 
representing all specialties, were also available. 

As the fighting progressed farther from the 
original landing beaches, LST (H)'s were em- 
ployed to pick up casualties at selected landing 
beaches up and down the island, sometimes 
almost at the flank of the fighting, thus saving 
long ambulance hauls over dusty and vehicle- 
choked roads. Efficient and ample air evacua- 
tion facilities were also set up early with the 
result that approximately half of the casualties 
were evacuated to rear bases. 

Following the breakthrough at the Shuri 
Line, a rapid advance of from 3 to 4 miles was 
made on the entire southern front. Before hos- 
pital facilities could be moved up in close sup- 
port, heavy rains lasting almost a week made 
the roads leading from the front practically 
impassable. Several medical companies employ- 
ing surgical trailers, were able to get up for 
close support, although evacuation for a time 
was extremely difficult or impossible. 

After some initial difficulty, an LST(H) was 

able to make contact with an evacuation station 
in Naha Harbor and took many casualties out, 
distributing them each night to hospital ships 

or APA's. The corps surgeon made arrange- 
ments with boat pools for LCM's and LCT's to 
carry patients from the flanks of the fighting 
to beaches opposite the rear hospital instal- 
lations. LVT's evacuated some patients directly 
to supporting naval gunfire ships. Finally, a 
small strip of land was cleared and L-5 planes 
evacuated almost 1,400 casualties. With the use 
of five different agencies, an almost hopeless 
situation was averted, demonstrating the flexi- 
bility of the evacuation facilities and the de- 
mands occasionally placed on them. Captain 
0. B. Morrison (MC) USN, who directed the 
evacuation, was commended for accomplishing 
this extremely difficult task. 

An amphibious operation requires a vast 
amount of planning, forethought, and training 
on the part of both the line and the staff. This 
includes the staff medical officer, who builds 
his plans in accordance with the best intelli- 
gence estimates, the surgeon, who molds his 
men into a smoothly functioning team, and 
the company first-aid man, who must learn all 
the tactics of the fighting man in addition to 
mastering lifesaving first-aid measures. There 
is no place for the man not thoroughly indoctri- 
nated in the part he is to play. 

The Medical Department must keep pace 
with the rapid strides in the development of 
tactics and weapons. The devotion to duty and 
untiring efforts which marked the perform- 
ance of the medical men in the amphibious 
forces will not suffice if we da not keep abreast 
of the changing picture and constantly train 
medical personnel to act as the core of an 
expanding force in time of war. 

Chapter VII 

Medical Service in the Seventh Amphibious Force 

EmmeH D. Hightower, Capfaln (MC) U3N 

Two major problems confront military med- 
ical services: (a) the treatment of wounded 
men and their return to duty, and (6) the 
treatment of those acutely ill. Because seasoned 
and well-trained personnel are of inestimably 
more value than raw recruits and there is 
always only limited manpower, it is imperative 
that the medical service not only strive to 
shorten the period of healing, making possible 
early return to duty, but also institute hygienic 
and preventive measures to limit the incidence 
of disease. 

Warfare in the Southwest Pacific involved 
island-to-island moves and presented, in addi- 
tion to the task of caring for combat casualties, 
hazards to the health of both combatant and 
noncombatant personnel from malaria, enteric 
diseases, scrub typhus, and tropical skin 
diseases. Further, there existed the potential 
danger of mental breakdown from combat, close 
restraint, the confinement of long months at 
sea, and a lack of recreational facilities. 

In World War II the health standards of the 
troops and the survival rate among the wounded 
were unequalled. Perhaps one of the most im- 
portant factors contributing to this fine record 
was the cooperation of military commanders 
with the Medical Department. Directives relat- 
ing to preventive measures were disseminated 
for compliance to all units by dispatch or letter. 
The health records of all newly arrived men 
were reviewed, because many men reported 
who had not received the necessary inocula- 
tions. Malaria discipline was rigidly enforced, 
although not always successfully. W^th many 
small craft constantly in touch with the beach, 
the malaria rate was higher in the early days 
than it should have been. As an example, an 
LST beached overnight in a New Guinea port 
^nd 25 members of her crew contracted malaria. 

No serious epidemics of disease occurred in 
ships of the force, nor w^ere there any serious 
outbreaks of food poisoning. Respiratory infec- 
tions were not a problem among personnel 
afloat, although on one occasion six officers on 
a destroyer escort had virus pneumonia and 
the ship was unable to get underway for a 
week. The hot, humid environment caused 
prickly heat of varying degrees in practically 
all men. It was necessary to transfer some to 
a temperate climate. 

The hygiene and sanitation in all ships was 
maintained at a high standard, which was 
remarkable considering the fact that they were 
manned by inexperienced men who had little 
time for upkeep. The limited supply of fresh 
water was the greatest problem in small craft. 
Opportunities for bathing were limited and it 
was necessary to use a minimal amount of 
water in the scullery and washing machine. 
Despite these limitations, no ill effects attribu- 
table to a lack of water were noted. 

Because the early symptoms of mental break- 
downs were not always discernible, the problem 
of prevention remained unsolved. In most men 
it appeared to be caused by environmental 
factors rather than combat, and was related 
to the close confinement and monotony of many 
months at sea, togeth er with the lack of recrea- 
tion and entertainment facilities. 


The number and type of landings that were 

to be made on enemy-held islands required a 
smoothly functioning system of casualty care 
and evacuation. Because the distances to rear 
bases became greater as operations proceeded 
and casualties occurred while en route to as 
well as on the landing beaches, and because 



some time was required for Army facilities to 
become operative, it devolved upon the amphib- 
ious forces to furnish means for early and 
adequate surgical care of the wounded at the 
far beach. Transportation and care of patients 
while en route to the rear was also necessary. 
Therefore, the medical plan was based on the 
assumption that the forces afloat would be 
responsible iot treatment and transportation 
of casualties until the Army hospitals were 
operative ashore. The time varied, depending 
on the resistance encountered, terrain, weather, 
and speed of cargo unloading. Close liaison was 
maintained with the Army Medical Department 
at all times — the teamwork left nothing to be 

In every assault landing each ship assigned 
had the maximum medical facilities for the 
care of casualties, and preparations were 
always made for a large number of them. The 
Seventh Amphibious Force contained amphib- 
ious craft exclusively. No APA's were assigned 
to it permanently. For almost a year after the 
Southw^est Pacific campaign began, it was nec- 
essary to transport casualties in LSTs, LCI's, 
and even hCTs, While these types are not 
desirable for long hauls, they could be used for 
short distances. 

The operation at Lae, New Guinea, on 4 
September 1943, involved the landing of 16,600 
Australian troops from 13 LST's, 20 LCFs, 
and 4 APD's in an area firmly held by the Japs. 
Each of the LST's carried one medical officer 
and equipment for emergency surgery. One of 
the LCI's had a medical officer aboard, the 
rest only corpsmen. 

There were 2 Army General Hospitals at 
Buna and Army casualty clearing stations at 
Milne Bay and Morobe, totaling about 3,000 
beds. The U.S.S. Rigel and the LST the 
first LST which had been converted to a hospital 
facility, were at Milne Bay to receive Navy 
casualties. Evacuation from the beach was the 
responsibility of the engineer special brigade 
and a regimental medical detachment. 

The landing was unopposed and casualties 
were few, but air attacks on the convoy while 
en route resulted in 37 naval personnel killed 
and 40 wounded, and among the embarked 
troops 36 were killed and 51 wounded. The 

wounded were cared for aboard DD's, APD's 
and LST's and were returned as soon as pos! 
sible to the rear. This experience was not 
forgotten. Obviously, if air attacks were to be 
a feature of the approach to the landing beach 
a ship should he designated and equipped with 
facilities to care for casualties sustained while 
en route. 

The Finschhafen, New Guinea landing was 

made on 22 September 1943. One week follow, 
ing the landing only 134 casualties had been 
returned to the rear areas. This operation 
demonstrated the need for a naval medical 
officer and hospital corps personnel to be with 
the naval beach party. The medical officer would 
be able to classify and move the wounded more 
quickly because of his knowledge of the bed 
capacities of the ships and the medical special- 
ists available on them. He also could render 
treatment in the event personnel of the beach 
party sustained injuries. 

The landing force at Arawe, New Britain, 
on 15 December 1943, consisted of about 4,000 
men. By the time the assault was made, the 
force surgeon had organized several surgical 
teams, each composed of 2 surgeons and 10 
hospital corpsmen. They constituted a mobile 
unit that could be shifted from ship to ship on 
short notice. For the Arawe landing, two teams 
were placed in LCT's, no LST's being used. 
Casualties were light, the majority occurring 
on D-day. About 60 men were killed or 
wounded. The wounded were treated by the 
surgical teams and evacuated via APD's. 

The use of the surgical teams in LCT's was 
a makeshift for this particular o})eration and 
it was not intended to employ them again in 
this manner. The conversion of LST's for the 
care of casualties entailed the installation of a 
watertight hatch in the tank deck bulkhead, 
thus affording access to the forward troop com- 
partment from either port or starboard. Spaces 
were converted into a receiving room, sterilizer 
and scrub-up room, and operating room, with- 
out interfering with the ship's capacity to carry 
troops and cargo. Thus, wounded could be 
brought in over the ramp, onto the tank deck, 
and passed into the receiving room through 
the hatch. The ship's medical officer was re- 
sponsible for triage, those requiring surgery 



being prepared for the surgical team, and 
those with minor injuries being treated on the 
spot. The flow of patients was from forward 
to aft, from the receiving room to the troop 
sleeping spaces. These ''surgical" LST's were 
obviously of limited capacity and it was not 
desirable to use them for transporting wounded 
for long distances, but the lack of hospital ships 
and the nature of the warfare made their use 
imperative if the wounded were to receive 
early definitive treatment. 

In the Cape Gloucester invasion on 26 De- 
cember 1943, 24,000 men were landed. This 
operation marked the first time that surgical 
teams were embarked in LST's converted for 
casualty care, and the first time that a naval 
beach party functioned. The beach party med- 
ical officer v^orked in conjunction with the 
medical elements of the First Marine Division 
in the evacuation of casualties. In addition to 
the surgical teams, one medical officer was 
carried by each LST engaged in the landing. 
Naval Base Hospital No. 13 was by this time 
in commission at Milne Bay. It had a capacity 
of 400 beds. Other rear area reception centers 
consisted of Army hospital facilities at Buna, 
Finschhafen, Goodenough Island, and Milne 

The casualties suffered in the initial phases 
of this assault were 6 killed, 37 wounded, and 
124 missing. These for the most part were due 
to enemy air attack. The wounded were trans- 
ferred after initial treatment by APD and LST 
to LST JfGJf and later to Base Hospital No. 13 
at Milne Bay. 

The value of the surgical teams was clearly 
demonstrated in this landing and all future 
plans for casualty care were based on their 
presence on the assault beach. The pattern for 
the over-all care and evacuation of casualties 
was by this time completed. The beach party 
medical sections received the wounded on the 
beach and were responsible for their evacua- 
tion. LST's with surgical teams were distrib- 
uted in initial and succeeding echelons of 
ships and some of them were designated to 
remain on the beach or to lie off the beach as 
long as necessary. As their facilities became 
overtaxed they would unload patients into 
departing ships. There remained only the 


organization of more surgical teams and the 
conversion of more LST's for casualty care. 

Throughout the spring and summer of 1944 
assault landings continued, about 81,000 troops 
being landed. Because lines of communications 
lengthened with each new landing, the trans- 
porting of casualties in amphibious craft was 
avoided when possible. Early and adequate 
surgical treatment at the far beach was 
stressed. Each assault echelon was accompanied 
by surgical teams and the wounded were trans- 
ferred to large, fast ships for return to the 
rear. An APH and one AH were available for 
the first time at the Aitape-Humboldt-Tana- 
merah landings. 

While these operations were in progress, rear 
area bases were being consolidated in prepara- 
tion for future campaigns. Both Army and 
Navy medical facilities were brought forward. 
Naval Base Hospital No. 15, with 1,000 beds, 
was commissioned at Manus. Outlying dispen- 
saries and a G-2 component made another 1,000 
beds available there. Base Hospital No. 17 
was moved into Humboldt Bay and Base No. 
16 into Woendi. These facilities permitted hos- 
pitalization in the forward areas and obviated 
the necessity for the long trip to Milne Bay, 
Brisbane, and Sydney. 

A blood bank was established in LST Jf,6Jf, It 
furnished whole blood for the surgical teams 
prior to their departure. The Army 24th Gen- 
eral Hospital at Hollandia also established a 
blood bank and provided blood to naval facili- 
ties when it was needed. Donors for both these 
banks were obtained from service personnel 

A total of about 85,000 troops were landed at. 
Leyte on 20 October 1944, with the help of 
APA's temporarily assigned to Seventh Am- 
phibious Forces. Preparations were made for a 
large number of casualties and the following 
medical plan was evolved : 

A-minus-3-day. — Two APD's to accompany 
and afford medical services to the mine- 
sweepers which were engaged in clearing 
channels to the landing beaches. 
A-day — Eight surgical teams in LST's. Five 
surgical specialty teams (orthopedics, 
anesthesia, urology, chest surgery, and 
ophthalmology) . Seventeen LST's with one 



medical officer. Eighteen APA's, each with 
3-5 medical officers aboard. The ship capac- 
ity on A-day accommodated 3,105 stretcher 
and 7,025 ambulatory patients. 
A-plus-l-day — A hospital ship to be present 

from 0600 to 1800. 
A-plus-2-day — Seven LST's with surgical 
teams. Twenty-four LST's with one med- 
ical officer. Seven APA's ; total bed capac- 
ity being 1,785 stretcher cases and 4,300 
A-plus-3-day — One hospital ship. 
A-plus-4-day — Six LST's with surgical teams. 
Sixteen LST's with one medical officer. 
Total bed capacity, 525 stretcher and 1,400 
ambulatory. LST ^^4, with a fresh supply 
of whole blood. 
A-plus-5-day — One hospital ship. 
A-plus-7-day — One hospital ship. 
The hospital ships assigned to this operation 
were the Army-staffed Mercy, Comfort, Tas- 
man, and Maetsiiycker, In addition, the Navy 
hospital ships Solace, Relief, and Bountiful 
were available at Ulithi. Casualties were light. 
At the end of the second day there were 83 
men killed and 145 wounded. 

Japanese plane attacks on naval shipping 
were heavy and suicide planes were encountered 
for the first time. On the first day there were 
9 killed and 40 wounded in the ships anchored 
in Leyte Gulf. Because of this vicious air 
action, all ships were moved out of the Gulf 
as rapidly as possible after they unloaded. Hos- 
pital ships were not permitted to enter the 
Gulf until the situation improved, and even 
then they were not allowed to remain longer 
than 2 or 3 hours at midday. Due to the abomin- 
able weather, the Army hospitals could not be 
set up as rapidly as anticipated, and with ships 
forced to depart early the LST Jf6U became the 
most important medical facility afloat for sev- 
eral days. 

Several lessons were learned at Leyte. For 
example, means must be devised to furnish med- 
ical assistance quickly to ships struck by 
bombs or suicide planes. The necessity of 
leaving surgical team LST's beached after un- 
loading was emphasized. One or two surgical 
LST's must be held in reserve to send to 

beaches overwhelmed with casualties or left 
without medical facilities. 

The operation at Lingayen Gulf on 9 January 
1945 was a major amphibious assault from 
bases in Leyte and New Guinea, 2,150 miles 
away. Ships in convoy were in danger of enemy 
air, surface, and submarine attack for the 
greater part of that distance. Intelligence indi- 
cated strong enemy resistance and heavy 
casualties were anticipated. The following prep, 
arations were made: 


Blue Beach: Two Seventh Phib beach par- 
ties ; 2 from APA's ; 6 LST's with surgical 
teams; 11 LST's with 1 medical officer. 
Nine APA's with 3 to 5 medical officers; 

1 APH with 8 medical officers ; 1 LS V with 

2 medical officers. 

White Beaches 1 and 2: Two Seventh Phib 
beach parties; 1 APA beach party; 3 
LST's with surgical teams; 4 LST's with 
1 medical officer; 5 APA's with 3 to 5 
medical officers. 

White Beach 3 : Two APA beach parties ; 2 
LST's with surgical teams; 1 APA with 
4 medical officers. 

S-plus-2-day : 

Blue Beach: Tw^o APA's with 4 medical 
officers each. 

White Beaches 1 and 2: Two LST's with 
surgical teams; 1 APA with 4 medical 
officers; 1 APH with 8 medical officers. 

S'pluS'i-day : 

Blue Beach: Seven LST's with one medical 

White Beaches 1 and 2 : One LST with sur- 
gical team ; 11 LST's with 1 medical officer. 

Six of the LST's with surgical teams were 
beached to provide casualty care after unload- 
ing. Beach party sections had orders to place 
only those patients in need of surgery aboard 
the surgical LST's, and to send the other 
wounded directly to APA's. This was done so 
that LST's would not become crowded with 
minor cases, leaving them free to care for 
those requiring actual surgery. APA's were 
scheduled for early departure from the area, 
and it was deemed advisable to evacuate as 
many wounded as possible in them. ] 



The APH's had about 8 medical officers 
aboard, and a bed capacity of over 1,000 ; they 
^vere held in the transport area as evacuation 
ships. When their bed capacity v^as reached 
they sailed, because it v^as not advisable to 
expose them to air attacks. There were no 
hospital ships available at Lingayen, as none 
was permitted in v^aters of the Sulu and South 
China Seas until the middle of February. 

Three PCE(R)'s v^ere given additional med- 
ical personnel and supplies and assigned to 
rescue duty only. These ships v^ere fast and 
maneuverable and v^ere able to go alongside 
stricken ships to render medical aid and take 
off survivors. One was kept at anchor near the 
flagship, within easy visual signaling distance, 
so that it could be dispatched on a mission 
without delay. The others were placed at stra- 
tegic places in the anchorage areas. One LST 
with surgical team embarked was held in re- 
serve to act as relief for LST's on the beach 
whose personnel needed a respite. 

Opposition was light, except on White 
Beach 2, and the landing forces advanced in- 
land rapidly. By the end of the sixth day only 
727 wounded had been evacuated to the rear. 
Had casualties been heavy, evacuation facili- 
ties would have been somewhat strained be- 
cause, with the hospitals at Leyte Gulf filled 
to capacity with sick and wounded, it would 
have been necessary to transport those from 
Lingayen as far as Hollandia and Manus. This 
would have interfered with the schedules for 
the resupply echelons of large ships. With fa- 
vorable weather and surf conditions through- 
out the initial phases of the landing, cargo was 
moved ashore rapidly and the Army was able 
to erect its field and evacuation hospitals very 

Whole blood for this operation was obtained 
both from the LST JfGA and from the Whole 
Blood Distribution Center at Guam. All ships 
departing from the transport area were di- 
rected to deliver their unused supplies of blood 
to the beach parties for further transfer to 
the Army. 

The operation at Bataan-Corregidor on 15 
February 1945 entailed the forcing of Mari- 
veles Bay and the capture of Corregidor. One 
paratroop regiment, a regimental combat team, 

and a battalion made the landing. Three LST's 
with surgical teams were assigned. Casualties 
were heavy. The first wave of paratroopers 
suffered 178 casualties due to the drop. Three 
were killed and 175 had fractures and dis- 
locations when wind carried them onto adverse 
terrain. Within 3 days the surgical LST's had 
over 600 seriously wounded aboard. The hos- 
pital ship Hoi^e arrived in Subic Bay and took 
the patients from the LST's, thus easing the 
situation. The Hoj)e was the first hospital ship 
that was allowed on the western side of the 
Philippines and she came at an opportune time. 

With a deluge of fractures, dislocations, and 
burns, the surgical teams almost ran out of 
supplies, but plaster, blood, and plasma were 
flown in from Leyte before the shortage be- 
came acute. 

Dental facilities. With hundreds of small 
craft in the Seventh Amphibious Force on mis- 
sions that kept them at sea for long periods, 
it was mandatory that dental facilities be pro- 
vided. Accordingly 10 mobile dental units were 
organized and placed in LST's and LCPs. These 
units consisted of a dental officer, a dental tech- 
nician, and a portable dental machine. Upon 
completion of the dental treatment on one ship, 
they moved to another. Their services were in- 
valuable. Facilities for prosthesis were avail- 
able in the U. S. S. San Clemente and the 
U. S. S. Dobbin, of the Seventh Service Force. 


An amphibious training center was estab- 
lished at Milne Bay, New Guinea in January 
1943 and functioned until October 1944. Its 
primary purpose was the training of troops 
in the methods used in amphibious assaults. 
Medical officers received instruction in the care 
and evacuation of casualties and were briefed 
regarding reports and returns, sanitation of 
ships, and prevention of diseases prevalent in 
the area. 


With the establishment of the base at Milne 
Bay and the beginning of operations in the 
New Guinea-Bismarck-Archipelago area, a 
floating hospital facility was urgently needed. 
There were no hospital ships in this force, so 



the LST JfGJf was converted into a hospital. The 
tank deck was partitioned into offices, operat- 
ing room, laboratory, x-ray room, isolation 
ward, and storeroom. 

Its function was threefold : To make medical 
facilities available to personnel of small craft 
that had no medical officer aboard; to receive 
and care for casualties brought from the land- 
ing beaches; and to furnish medical facilities 
to the personnel who were constructing ad- 
vance bases, prior to the time the advance base 
dispensaries or hospitals were in operati(^n. 

The Jf6U was staffed with a surgeon, intern- 
ist, dermatologist, urologist, EENT specialist. 
Hospital Corps officer, and initially about 40 
hospital corpsmen. Later, an anesthetist and 
psychiatrist were added. Additional surgeons 
were placed aboard for temporary duty if 
needed. The total bed capacity was 175, but 
the limited messing and laundering facilities 
on this type of ship made a rapid turnover of 
patients desirable. 

In the early operations at Lae, Finschhafen, 
Arawe, and Cape Gloucester, the J^SJ^ was sta- 
tioned at advance bases, usually Cape Sudest, 
Morobe, or Buna, in order to receive casualties 
from the amphibious craft and transport them 
to hospitals in Milne Bay. After Humboldt Bay 
was seized, the JfOJf proceeded there to act as 
station hospital ship for the construction bat- 
talion and other personnel who were building 

the base. She remained in Humboldt Bay 
furnish supplies and whole blood, and to mai^^ 
her facilities available to small craft. 

When the attack on Leyte was made, the 
was used primarily to furnish blood to ship^ 
and to care for casualties if necessary. In th^ 
latter capacity she inadvertently assumed a 
stellar role. Because of the intense enemy air 
attacks, the hospital ships were not permitted 
to enter the Gulf. Because the weather pre. 
vented Army hospital facilities from being 
erected as early as planned, the J^GJi, became 
the main facility for the care of the casualties 
in the area. She was armed and had no dis. 
tinctive markings of a hospital ship and was 
therefore, under air attack frequently. Her 
staff worked to the point of exhaustion and 
most of them had to be relieved because of 
fatigue. After several days, hospital ships were 
permitted to enter the Gulf, but remained 
only a few hours, so that the only assistance 
they rendered was that of taking out the pa- 
tients from the A6i, 

With the completion of the Leyte Operation, 
the Jf6^ remained in Leyte Gulf to act as sta- 
tion hospital ship for small craft until late 
in March 1945 when she was sent to Subic Bay 
for the same purpose. In September she was 
ordered to Jinsen, Korea, where she remained 
about 3 weeks to furnish medical services to 
naval personnel. 

Chapter VIII 

Medical Aspects of Naval Operations 
in the Mediterranean 

Frederick C. Greaves, Rear Admiral (MC) USN 

The Mediterranean campaign began with the 
Allied landings in French Morocco and Algeria 
on 8 November 1942, and continued through 
the North African, the Sicilian, the Italian, 

and the Southern France campaigns to the 
final dov^nfall of Nazi Germany on 8 May 

Organization of the Naval Medical Department 

The first contingents of United States naval 
personnel to arrive in North Africa after the 
landings included medical department officers 
and men and sufficient equipment for the dis- 
pensaries at the proposed bases. Quonset huts 
for housing were available. In many cases, 
when the new bases were established, perma- 
nent buildings were requisitioned when they 
were found to be more suitable than quonset 
huts. No serious difficulties were experienced 
in acquiring quarters of suitable size from the 
French Government by requisition through the 
U. S. Army. Such quarters, however, were 
always deficient in plumbing and electric light- 
ing facilities. It was usually possible to im- 
prove them by substituting American equip- 
ment, and these facilities were eventually im- 
proved to a point where they approached Navy 
Medical Department standards. 

Only dispensary facilities were provided for 
the new bases. Patients requiring hospital care 
and treatment were transferred to the nearest 
U. S. Army hospital. As the U. S. Navy instal- 
lations in the theater grew beyond the scope 
oi'iginally contemplated, particularly in and 
near Casablanca and Oran, the need arose for 
U. S. Navy base hospital facilities, and the 
enlarged and overgrown dispensary in Casa- 
blanca was commissioned as Base Hospital 
No. 5 in May 1943. A 500-bed quonset hut 

hospital was built at Oran and commissioned 
Base Hospital No. 9 in November 1943. These 
two hospitals served as the hospitalization cen- 
ters for U. S. Navy personnel throughout the 
campaigns. Base Hospital No. 9 was particu- 
larly well located because of the lines of air, 
sea, and rail communications connecting Oran 
with advanced areas to the east and oversea 
communication for the evacuation of patients 
to the United States. 

Base Hospital No. 5 was used principally for 
the hospitalization of personnel from the bases 
and naval groups in French Morocco. Its loca- 
tion permitted easy evacuation of patients by 
air to the United States by the Naval Air 
Transport Service and by the Air Transport 
Command, from Port Lyautey and Casablanca, 

The dispensaries established at the Naval 
Air Station, Port Lyautey, and at the Naval 
Base, Palermo, Sicily, were of adequate size 
and had sufficient personnel and equipment to 
enable them to furnish hospital care of all 
types. Both performed valuable and satisfac- 
tory work. The Port Lyautey dispensary was 
set up in one wing of the civilian Municipal 
Hospital. When a 100-bed quonset hut dispen- 
sary, with complete hospital facilities, was 
constructed on the base in January 1945, the 
dispensary in the Municipal Hospital was 




closed. The Palermo dispensary was the only 
American military hospital in Sicily during the 
last year of its existence. It was disestablished 
in 1945. 

The advanced amphibious training base at 
Arzew had a 100-bed dispensary set up in 
quonset huts. As soon as the Allied Forces 
gained military control of the Bizerte-Ferry- 
ville-Tunis triangle the main component of the 
amphibious force was moved forward into the 
area. The new site was the French Naval Base 
at Karouba and La Percherie and the medical 
department moved into the French naval in- 
firmaries. These had been battered by bomb- 
ing attacks but were rendered serviceable after 

In the forces afloat the smaller ships trans- 
ferred patients to larger ships or to shore es- 
tablishments, using U. S. Navy facilities when- 
ever possible, and when these were not present, 
U. S. Army, British Army, or civilian hos- 
pitals. The larger ships, particularly the trans- 
ports, had excellent sickbays and were able 
to care for all type of cases ; they were of great 
assistance to the smaller ships and smaller 

The procurement of medical supplies was an 
extremely difficult problem for the U. S. Navy 
bases during the first few months of their ex- 
istence. This was due primarily to a misunder- 
standing on the part of both the medical offi- 
cers in the field and the Medical Supply Depot 
in Brooklyn in the matter of shipping priori- 
ties for the theater. The Combined Chiefs of 
Staff had assigned control of all shipping into 
the theater to the U. S. Army Service of Sup- 
ply (later the Service Command) and cargoes 
were loaded on the east coast in accordance 
with assigned priorities. Except for Navy car- 
goes loaded into U. S. Navy ships destined for 
assignment in the theater, no Navy cargoes 
were loaded at east coast ports unless they 
were authorized by a priority approved by the 
Service of Supply. Medical Department requi- 
sitions were sent in regularly by the bases and 
were filled by the Naval Medical Supply Depot, 
but nothing happened beyond that stage. When 
stocks in the naval medical activities became 
dangerously low it was discovered that non- 
shipment was due to a failure to establish ship- 

ping priorities and this difficulty was quickly 
resolved by obtaining the necessary priorities. 

Navy Medical Storehouse No. 9 was set up 
in Casablanca and continued to operate until 
it was transferred to Oran in the spring of 
1944. Most of the medical supplies and equip, 
ment were obtained directly from the store, 
house after its establishment. A very appre- 
ciable amount of stores and equipment was ob- 
tained from the U. S. Army, especially 1^. 
mediately preceding operations, because of the 
better availability of numerous Army Medical 
Supply Depots. 

Cooperation between the Medical Depart- 
ments of the Army and Navy was very satis- 
factory and improved steadily throughout the 
Mediterranean campaigns. U. S. Army hos- 
pitals rendered a great deal of medical care 
and treatment to the U. S. Navy personnel. 
This was in keeping with the plans made by 
the Combined Chiefs of Staff before the in- 
vasion of North Africa. Later, the original 
plans were supplemented and these arrange- 
ments were combined, thereby avoiding dupli- 
cation of logistical efforts. This arrangement 
was satisfactory and workable in its broader 
aspects but it presented problems in execution 
requiring adjustment. These arose from the 
differences in the administrative procedures of 
the two services. 

The Army employs a centralized system of 
its medical records. The person's health record 
is retained in The Office of the Surgeon Gen- 
eral, in Washington, and pertinent additions 
to it are added by forwarding them from the 
field. Thus, the activities in the field never have 
more than the current records with which to 
be concerned. The Navy, on the other hand, 
used a partly decentralized system wherein the 
health record is retained by the individual's 
medical officer, and clinical record sheets are 
forwarded to the Bureau of Medicine and Sur- 
gery at specified times for inclusion in the 
individual's jacket. The descriptive sheet, the 
medical abstract, the immunization record, and 
the dental record are retained in the health 
record. Navy regulations places responsibility 
for the custody of Health Records with the 
individual's commanding officer and medical 
officer, and provides for records of transfer 


^hen health records are transferred with indi- 
viduals from one command to another. 

When Navy personnel were transferred to 
Army hospitals, the Army assumed respon- 
sibility for their medical care and treatment, 
jlowever, the Navy retained full jurisdiction 
over them. They were not '*lost'' from Navy 
records and rolls. Great confusion existed dur- 
ing the first 6 months of the North African 
campaign in the matter of Navy patients sent 
to Army hospitals. Naval medical officers and 
commanding officers followed Navy Regula- 
tions when they transferred patients and sent 
all the records with them to the Army hos- 
pitals. The Army medical administrative staffs, 
not being familiar with Navy records, usually 
let them get adrift. No distinction was made 
for Navy patients in the matter of evacuation 
to the rear, or to the zone of the interior, and 
health records, pay accounts, and service rec- 
ords of Navy patients were scattered all the 


way from Tunisia to the United States with- 
out anyone (Army or Navy) knowing where 
they were. The Army was not in a position 
to do much about preventing the confusion. 
They were busy handling the sick and wounded 
of an expanding force engaged in active com- 
bat operations and had no time to reeducate 
their medical personnel in a system that was 
applicable only to Navy personnel. The prob- 
lem was solved satisfactorily by local agree- 
ment ; certain Army hospitals in each area 
were designated to which Navy personnel 
would be transferred, and Navy medical 
personnel were assigned to those hospitals 
to assume custody of and maintain person- 
nel records of Navy patients, to monitor 
their transfers to other hospitals, and to re- 
port such transfers to the cognizant Navy 
commands. In the spring of 1944, the whole 
matter was clarified on a service- wide basis by 
a joint Army-Navy directive. 

The Naval Medical Corps 

In the three major amphibious operations 
in the Mediterranean and the several amphibi- 
ous landings that were made in support of 
these operations, including those at Anzio and 
the capture of the islands in the Tyrrhenian 
Sea, the Navy Medical Department's respon- 
sibilities included: 

1. Furnishing medical care for the personnel 
of all services while embarked in U. S. Navy 

2. Furnishing seaward evacuation of all cas- 
ualties from the assault areas until the Army 
became sufficiently established to treat, hold, 
and evacuate in a routine manner. 

The chain in casualty evacuation included 
the medical section of the Navy Beach Battal- 
ion on the invasion beaches; the ambulance 
boats running between the beaches and the 
transports and hospital ships lying offshore, 
and the landing craft running in close enough 
to the beaches to receive casualties directly 

The duties of Navy Beach Battalions, includ- 
ing the medical sections, are difficult and ar- 

in Amphibious Operations 

duous. They land in one of the first waves and 
perform their duties frequently under fire dur- 
ing the difficult and confusing period of over- 
lapping Army and Navy jurisdiction. A clear- 
cut assignment of the division of responsibili- 
ties and adequate training of the Army and 
Navy medical sections in their duties are es- 
sential for efficiency. The Army must assume 
responsibility for the care of casualties land- 
ward of the high watermark and for their 
transportation to the Navy Beach Battalion 
evacuation stations. The Navy must care for 
casualties in the evacuation stations and for 
their evacuation seaward. An evacuation rec- 
ord is very important. The system found to 
be most satisfactory in the Mediterranean The- 
ater was for the Army to furnish the Navy 
with a list of all personnel brought by them 
to the Navy evacuation stations and for the 
Navy to use this as a check-off list for all sea- 
ward evacuations, adding the names of those 
for whom they initiated treatment and whom 
they later evacuated. The check-off lists were 
then forwarded to the Army Medical Section 
for their permanent records. 

258015—58 14 



No attempt was made to evacuate casual- 
ties until after assault troops and equipment 
v^ere landed, except personnel w^ounded in 
landing craft en route to the beaches. Per- 
sonnel so vs^ounded were never landed, except 
in the event the landing craft was disabled, 
because ineffectives on an assault beach are of 
no military value and their presence increases 
the tasks of the beach parties. They were given 
first aid in the small boats, retained aboard, 
and returned to the mother ship. 

Small craft returning to the transports or 
hospital ships with casualties transferred their 
patients either by litter hoist or by hoisting 
the ambulance boats to the rail and transfer- 
ring the patients directly to the deck. The most 
expeditious method from a military standpoint 
was to keep one boat, usually a disabled one, 
permanently rigged for hoisting and to have 
the ambulance boats come alongside to trans- 
fer their patients. 

Landing ships, tank (LST's) were available 
as evacuation ships. An operating room was 
set up on the forward part of the tank deck. 
They are acceptable evacuation ships and meet 
the requirements for emergency evacuations 
when other facilities are not available. The 
Mediterranean is peculiar in that distances be- 
tween friendly shores and target areas are short 
enough to permit quick turn-around time for 
hospital ships of moderate speed but are too 
long for making use of LST's for casualty 
evacuation. LST's being combat ships and un- 
protected by the Geneva Conventions sailed in 
convoy and were legitimate targets for enemy 
planes. Medical planning in the Mediterranean 
included the use of LST's equipped for cas- 
ualty evacuation. Their routine use was lim- 
ited to the evacuation of ambulatory patients. 
Transports acted as hospital ships as long as 
they remained in the target areas. There were 
sufficient U. S. Army and British hospital ships 
to take over evacuation duties when the trans- 
ports left. 

In all three operations the commander of 
the U. S. Naval Forces Northwest African 
Waters (later the Eighth Fleet) was the Allied 
Naval Task Force commander, but the Royal 
Navy, under the Commander in Chief, Medi- 
terranean Fleet, exercised operational control 

of all naval craft in the theater, except those 
actually in the combat area. This arrangement 
was found to be unsatisfactory during the 
Sicilian campaign, insofar as it affected hos. 
pital ships. It required the Army commander 
ashore in Sicily, to request hospital ships fronj 
CinC, Mediterranean, by radio dispatch. The 
request was relayed to the Principal Sea 
Transportation Officer who issued the sailing 
orders. The plan was awkward and cumber- 
some and delayed casualty evacuation. In later 
operations all hospital ships, regardless of 
service or nationality, were put in a pool under 
the direct operational control of AFHQ. 

Hospital ships were not taken into the com- 
bat areas on D-day. They were not needed be- 
cause there were sufficient hospital and evacu- 
ation facilities aboard the ships of the invasion 
fleets and there was nothing to be gained in 
having them exposed to enemy attack in the 
confusion of D-day battles. Their protected 
status was respected for the most part by the 
enemy, except for three attacks, one of which 
was probably accidental but the other two defi- 
nitely deliberate. 

Evacuation ships delivered casualties to 
military hospitals in the rear medical echelon 
in accordance with plans agreed upon by the 
various services before the operations. Prior 
to reaching debarkation ports the ship's medi- 
cal officers prepared casualty reports in tripli- 
cate, giving the full name and rank or rate 
of each casualty aboard, his service number 
and organization, the time and date received 
aboard and the date disembarked, the diag- 
nosis and treatment received while aboard, and 
his condition at time of debarkation (favor- 
able, unfavorable, serious, or critical). Upon 
reaching the debarkation port the originals of 
these reports were mailed to the Detachment 
of Patients, U. S. Army. One copy was sent 
to the Commander Eighth Fleet and one copy 
retained in the ship's files. U. S. Army casual- 
ties were not reported to the War or Nav}' 
Departments. Navy casualties, including 
deaths, were reported to the cognizant Navy 
Department divisions in accordance with ar- 
ticle 908, Navy Regulations. Dead in ships in 
combat area were taken ashore as soon as pos- 
sible for burial by the Graves Registration 




gervice. Dead in ships at sea were retained 
board, if practicable, for burial ashore; if 
•g was not practicable, they were buried at 

Medical and Epidemr 

The experience of the U. S. S. Thomas Stone 
APA) was unique in the North African in- 
vasions. Early in the engagement this trans- 
port was beached approximately 100 yards 
from the exposed sandy beach at Algiers. De- 
prived of flotation and means of propulsion be- 
cause of torpedo and bomb action before and 
after the invasion, the ship was in other re- 
spects in perfect condition. Her excellent sick- 
bay proved to be a helpful supplement to the 
U. S. Naval Dispensary established shortly 
after the capitulation of Algiers, particularly 
for surgery, dentistry, laboratory work, and 
roentgenology. From all evidence, the medical 
department of the ship functioned during bat- 
tle in accordance with the best tradition of the 

In the Casablanca area, the first Navy medi- 
cal personnel destined to establish permanent 
shore establishments debarked at Fedala on 
10 November 1942. They established a tem- 
porary barracks and a small sickbay in a 
camel barn on the dock. 

A first-aid station was established in the 
port area of Safi on 9 November and a sick- 
bay at Casablanca on 12 November. On 18 No- 
vember a group of medical and dental officers 
arrived to establish the first dispensary at 
Casablanca. A permanent dispensary was es- 
tablished on 7 December 1942 in a clinic for- 
merly operated by a French physician. To meet 
increasing needs, neighboring villas were oc- 
cupied until there was room for 210 beds. 

There was a certain amount of misconcep- 
tion, particularly among the American forces, 
about the climate, the living conditions, and 
the diseases in French North Africa. The 
larger cities were found to have excellently ad- 
niinistered Pasteur Institutes, and organized 
Departments of Health were found in all com- 
inunities where Europeans form an appreci- 
able part of the population. Sewage was dis- 
posed of in a sanitary manner, the public water 

sea, an accurate report of complete identifica- 
tion, and time and place of burial being for- 
warded to the commander of the Eighth Fleet* 

ogical Considerations 

supply was safe to drink, food distribution was 
under sanitary regulations, and contagious 
diseases were isolated or quarantined. The 
Arabs, however, except for a very small 
wealthy minority, lived in poverty and squalor, 
and infestation by lice was almost universal. 
Malaria, tuberculosis, and the venereal dis- 
eases were widespread, infant mortality was 
high, and the gastrointestinal infections were 

In Sicily and Southern Italy, typhoid fever, 
the dysenteries, and other waterborne infec- 
tions were endemic. Malaria was widespread 
in the rural areas. The incidence of malnutri- 
tion, tuberculosis, skin disease, infant mortal- 
ity, and venereal disease was appallingly high. 
Typhus appeared in Naples in November 1943 
and an alarming sharp upswing in the inci- 
dence of the disease was immediately apparent. 
Had it not been for the heroic and previously 
untried use of DDT in a program in which ap- 
proximately 2 million persons were dusted one 
or more times within the space of a few weeks, 
a major public health catastrophe would have 

Marseilles was notorious for its high vene- 
real rate and its thousands of registered pros- 
titutes. Typhoid fever was prevalent the year 
round, about 60 new cases being reported each 
month during the summer season and some- 
what less that number during the winter 
months. The Public Health officials found that 
the infections resulted from eating shellfish 
taken from beds contaminated by raw^ sewage. 
Malta fever is sporadic along the Durance 
River north and west of the city. Fievre bou- 
tonneuse is also prevalent and is transmitted 
by the Ornithodoros tick. The soil of Southern 
France is heavily contaminated with tetanus 
spores and human cases of the disease are not 
uncommon. Marseilles reported the following 
communicable diseases for the period from 1 
June to 15 September 1944 : 




Typhoid fever 165 

Diphtheria ^9 

Scarlet fever 23 


Undulant fever 

' • Tetanus : * S,.- 

Cerebral meningitis . . . : . • • • ^ 

Tracoma ^ 

Leprosy ^ 

Malaria is endemic in the islands of Sar- 
dinia and Corsica. These islands were occupied 
after the capture of Sicily and were used as 
bases in support of both the Italian and South- 
ern France campaigns. In both Sardinia and 
Corsica malaria, typhoid fever, and dysentery 
constituted the main hazards to health. 


The first objective for the U. S. Navy in 
North Africa, after the landings, was the es- 
tablishment of suitable port facilities through 
which men and equipment could be funneled 
into the new theater of operations. One of the 
first bits of epidemiological information gained 
from the French was that the area surround- 
ing the city of Port Lyautey and the air base 
had the reputation of being the most malarious 
spot in all French North Africa. Forty percent 
of the French personnel at the base had the 
disease during the year immediately preceding 
American occupation. 

A survey conducted by a U. S. Navy Malaria 
Control Unit found that all the Arab huts 
within 5 miles of the base and many of the 
dwellings of the Europeans living near the 
base were infested with adult Anojjheles mac- 
idipennis freeborni and culiciform mosquitoes. 
Spleen rates among the Arabs were 90 percent 
for the children and 50 percent for the adults. 
Blood smears made on both Arabs and Euro- 
peans living in the area showed a high rate 
of parasitization, predominantly benign ter- 
tian, but with a significantly high estivo-au- 
tumnal number. Case histories of persons who 
had had the disease showed a high percentage 
of recurring attacks. ^ 

The French had attempted to control the 
disease with an extensive system of drainage 
ditches and a start had been made in a pro- 

gr-am to dust the lagoon with Paris green fronj 
low-flying planes. Antimalarial drugs had been 
made available to the Arab and European cU 
vilian population in an attempt to reduce the 
reservoir of infection. This part of the pro, 
gram met with the least success because the 
Arabs who constituted the principal danger 
from infection could not be made to cooperate 
when the program conflicted with their racial 
customs and religious beliefs. 

At the time of American occupation malaria 
constituted a real threat to the mission of the 
newly established naval air base. Positive and 
vigorous control measures were necessary. A 
rather complicated condition of overlapping 
spheres of influence existed. The U. S. Navj- 
operated and administered the base under the 
United States naval commander in the theater, 
who in turn was subordinate to the Com- 
mander in Chief of the British Mediterranean 
Fleet. It was an Army theater under the com- 
mand of the Supreme Allied Commander. The 
French Army and Navy were also a factor to 
be considered because every effort was bein^ 
made to rehabilitate their forces and this was 
being done in the garrisons and bases which 
they had controlled before the invasion. Co- 
operation was required between these different 
groups, but the important thing was to inaugu- 
rate a control program with a minimum of de- 
lay. The U. S. Navy indicated its desire and 
ability to assume full responsibility for pro- 
tecting all personnel stationed on the base. 

Fortunately, time was a factor that oper- 
ated on the side of the control program. The 
occupation of the base occurred shortly after 
the end of the 1942 malaria season and several 
months would elapse before the 1943 season 
would begin. A malaria control team, composed 
of a malaria control unit and a group of ap- 
proximately 50 construction battalion officers 
and men, was organized and given the task of 
rendering the base reasonably safe from ma- 
laria. Drainage ditches were cleared of vege- 
tation and all collections of water that could 
not be drained immediately were oiled at regu- 
lar intervals. Screens were installed on the 
windows and doors of all living spaces and the 
use of mosquito nets was made mandatory for 
all hands. Officers and men were thoroughly 



indoctrinated in malaria discipline, and care- 
lessness and deliberate breaches were im- 
jnediately punished. Liberty expired for all 
hands at sundown; everyone working in the 
open or in unscreened buildings after dark was 
j-equired to use mosquito repellents. Freon 
pyrethrum was sprayed in all living and sleep- 
ing quarters daily to kill adult mosquitoes. 

Attention was given to the dangers that ex- 
isted in the town and surrounding countryside. 
An extensive system of new drainage ditches 
was constructed in the swampy area at a dis- 
tance from the base. The lagoon was dusted 
regularly with Paris green from low-flying 
planes and later with DDT when this agent 
became available. The French and Arab in- 
habitants living nearby objected to this on 
the grounds that it was injurious to their live- 
stock, but their objections were overruled in 
the interest of the war effort. 

The reservoir of infection that existed in the 
civilian population was not ignored. Atabrine 
was made available for use by both Europeans 
and Arabs, but difficulties were encountered 
immediately with the latter. They could not be 
depended upon to treat themselves and they 
would not cooperate by coming to a central 
dispensing point, or with the medical officers 
and corpsmen who attempted to prescribe the 
drug for them in their huts. They would not 
permit members of the control team to enter 
their homes for mosquito eradication. Even- 
tually, the Arabs were relocated in new huts 
beyond the probable flying range of mosquitoes 
and the old huts destroyed. 

The United States and British Armies made 
the suppressive use of atabrine mandatory for 
all their forces in the North African Theater 
from mid-April to mid-November. The U. S. 
Navy did not adopt this policy but elected to 
depend upon mosquito control measures. The 
Port Lyautey area offered an excellent oppor- 
tunity to determine the efficiency of control 
measures alone when such measures were 
vigorously and intelligently administered and 
the group rigidly controlled. The test was suc- 
cessful. The incidence of malaria during the 
first year of American occupancy of the air 
base was less than one-half of 1 percent and 
the cases that did occur included men newly 

arrived from other theaters in whom recur- 
rences, rather than new infections, were pos- 
sible. The incidence of the disease showed a 
slight but steady decline during the remaining 
years of American occupancy. 

Malaria presented no problem in the other 
United States naval bases in French North 
Africa. This was due to the low incidence of 
the disease in the area where those bases were 
located and the antimalaria regulations prom- 
ulgated by the United States naval commander 
in the theater. 

It did not prove necessary to resort to the 
use of atabrine in any U. S. Navy base or for 
any U. S. Navy personnel operating under 
their commands. Army forces in camps and 
staging areas in all parts of the country, many 
of which were unsanitated, and those engaged 
in combat operations were compelled to rely 
upon suppressive treatment. 

Malaria is endemic in French North Africa 
and will always be a factor to be considered 
in military operations. The insect vector is 
found in all parts of the country and the hu- 
man reservoir of infection is constantly pres- 
ent in the Arab population, a race that is 
normally nomadic and whose movements are 
unpredictable and practically impossible to 
regulate. There is probably no part of the 
country where mosquito control measures will 
not be successful if sufficient time is allowed 
to place them in effect and if the required men, 
equipment, and materials are made available. 
The fact that the disease proved no serious 
handicap in this campaign indicates that pres- 
ent methods of malaria control are adequate in 
this particular region. 


Bacillary dysentery is endemic in the entire 
Mediterranean area, including French North 
Africa. The French Public Health authorities 
reported that mild diarrheal disturbances oc- 
curred in the spring, summer, and autumn 
seasons and that cases could be found in prac- 
tically every community. Flies are unusually 
prevalent during these seasons and undoubt- 
edly are an important contributing factor, as 
is the unsanitary manner in which the Arabs 
live. Every city, town, and village became war 



conscious immediately following the invasion, 
and in anticipation of heavy air raids, con- 
structed numerous slit trenches for their pro- 
tection in parks, gardens, and fields. The 
ubiquitous Arab very quickly discovered that 
they made excellent latrines and by the spring 
of 1943 it was most unusual to find one that 
had not been repeatedly fouled with human 
feces, unless it had been kept under the strict 
and constant surveillance of guards. 

Bacillary dysentery made its appearance 
early among the invasion forces in North Af- 
rica and continued to be a threat as long as 
they remained in the Mediterranean Theater. 
Fortunately, the disease occurred in a rela- 
tively mild form, but this was due entirely to 
luck and could not be attributed to any control 
measures. The fact that it occurred in any 
form was indicative of inefficient control. The 
principal offending organism was Shigella 
sonnet but at various times and in numerous 
places 70 enteric pathogens were isolated from 
active cases. Numerous cases of acute gas- 
troenteritis were studied in which Pseiido- 
monas aeruginosa was found in overwhelming 
numbers and occasionally in pure culture. 

The disease appeared in all the newly estab- 
lished bases during the spring of 1943. The 
outbreaks were explosive in character and af- 
fected most of the personnel within a few 
days. Most patients were well after about 1 
week under a regime of diet, sulfaguanidine or 
sulfathiazole, and rest. The commands were 
seriously handicapped by the attendant loss of 
manpower and urgently needed work was de- 

A definite pattern of unsanitary conditions 
was found to exist in all of the outbreaks. 
Flyproofing of latrines was frequently incom- 
plete and most haphazard. Galleys and mess 
halls were too frequently left unscreened. For- 
tunately, there was a universal distrust of the 
water supply at the new bases and Lister bags 
were used by all hands until the local supply 
was demonstrated to be safe. 

Sanitary control over the preparation and 
handling of food, sewage and garbage disposal, 
and water supply for drinking purposes was 
gradually established. Administrative officers 
were indoctrinated in the basic facts of dysen- 

tery control and medical officers and hosnu 
corpsmen were reeducated in the same 
ciples and in their responsibilities in the i^^^ 
ter. All galleys and mess halls were tighti 
screened against the entrance of flies, 
double swinging screen doors were installed at 
all entrances and exits. Mess gear was w 

in hot soapy water and rinsed in boiling wat^ 
and, whenever practicable, it was stowed be. 
tween meals in flyproof compartments. When 
this was not possible it was dipped in boiliijg 
water immediately before food was served 
Existing toilet facilities were improved and 
enlarged as materials became available. La. 
trines were abandoned as quickly as possible, 
and when this was not possible, they were ren- 
dered flyproof and frequently inspected to 
insure that they were kept so. The factor of 
carriers in food handlers was investigated. The 
potability of the local water supply was de- 
termined. An intelligent system of garbage 
disposal was placed in operation and fly-breed- 
ing places in the immediate vicinity of bases 
were eliminated with the cooperation of the 
local civil authorities. All personnel were in- 
doctrinated in preventive methods. Sporadic 
cases continued to occur all through the period 
that American forces were in the theater, but 
the infection in these later cases resulted from 
carelessness in choosing places to eat and drink 
on liberty. 

Bacillary dysentery is preventable and pre- 
vention should be a responsibility of the plan- 
ning staff before new bases are established. 
Prospective medical officers should enter into 
the planning phase to the extent that they are 
made conversant with the problems they are 
likely to meet, and should be given the requi- 
site authority to compel the cooperation nec- 
essary to insure complete protection from the 
very first day. 


Sand fly fever is endemic in the coastal areas 
of practically all the Mediterranean countries. 
Phlebotomus qmpatasii is indigenous and was 
found to be particularly prone to occur in large 
numbers in areas that had been heavily 
bombed. The rubble of the ruins apparently 
provided a desirable breeding ground as did 



jQYgronnd caves and caverns. The incidence 
the disease was unusually heavy at Malta 
^rhere repeated bombings had destroyed many 
^tructi^^^'^^ in the inhabited areas and all im- 
^ rtant military offices were located in caves 
^ d underground tunnels. The disease occurred 
I so regularly in the U. S. Navy personnel sent 
' ^here on temporary duty that a bout with the 
disease was considered standard operating 

The ordinary wire screening and bed nets 
used for protection against flies and mos- 
I quitoes offered no protection against the sand 
fly. These insects are small enough to pass 
through the mesh. P. papatasii is a weak flier 
and rarely travels any appreciable distance 
from the place of its origin unless transported 
artificially or by wind currents. Control meas- 
ures consist of eradicating breeding areas in 
and about the living and sleeping spaces. Rub- 
ble and refuse must be cleared away. Living 
spaces should be regularly and thoroughly 
sprayed with an insecticide. DDT proved to be 
^most effective. Particular attention should be 
Rpaid to the cracks and crevices in the floors 
and walls of buildings and to dark musty base- 
ments and subbasements. These simple precau- 
tions will do much to lessen the chances of 
infection from the insects carrying the virus. 


Typhus has always been a threat in the east- 
ern Mediterranean. Repeated epidemics have 
occurred in the Balkans, in Asia Minor, and 
in Egypt, where the disease has been endemic. 
No difficulty was experienced with typhus by 
the Armed Forces operating in the Mediter- 
ranean Theater, however, until December 1943 

Table 25. — Typhus cases and deaths in Naples 






March 1043 






























September __ 




















January 1944 








when an epidemic of major proportions was 
threatening in Naples. 

The exact origin of the Naples epidemic was 
never ascertained, but it was believed that a 
few cases occurred in March 1943 among some 
Serbian prisoners in an Italian prison camp 
near the city. Statistics made available by the 
ItaUans and from Allied records after the cap- 
ture of the city portray the course of the epi- 
demic (table 25). 

The opportunities for an epidemic were 
abundantly present: 

1. There was an original seeding of the 

population from infected persons arriving 
from the Balkans as prisoners of war. 

2. There was an extensive rise in the louse 
population of the community due to a disrup- 
tion of the water supply system, an absence 
of soap, and a lack of desire for personal 
cleanliness. Added to this was the onset of 
colder weather and the corresponding use of 
more clothing. Then there was the overcrowd- 
ing of the terrified population into the air raid 
shelters, where many lived for weeks at a time 
amid surroundings of indescribable filth. 

3. Food supplies were very short and actual 
famine existed among the poorer classes. 

4. Medical care was practically nonexistent 
and no attempt was made to isolate or quar- 
antine early cases. 

The epidemic remained confined to Naples 
for the first 10 months, but at the end of that 
period it began spreading southward, although 
the fighting moved northward out of Naples. 
The mortality rate was 16.5 percent which is 
surprisingly low in a nonimmune population 
(35 percent could have been expected) . The 
case incidence was highest in the 10 to 24 
age group and there was no apparent differ- 
ence noted between males and females. 

The initial phase of the control was started 
on 15 December 1943 by members of the 
Rockefeller Foundation Typhus Commission. 
The U. S. A. Typhus Commission assumed re- 
sponsibility for the control measures on 3 
January 1944. All suspected cases were inves- 
tigated by Italian-speaking officers. The pa- 
tients were deloused and all clothing and cov- 
erings with which they had come in contact 



were steam sterilized. All contacts with pa- 
tients were dusted with DDT. All buildings 
were dusted with DDT once a week as long 
as they were occupied. Stations for a mass de- 
lousing of the entire population were set up in 
42 locations in the city. The average station 
deloused 1,000 persons a day but as many as 
5,000 were treated in a day during the height 
of the program. The maximum number de- 
loused in 1 day in the city was 66,476, on 12 
January 1944. A grand total of 1,633,134 were 
deloused between 15 December 1943 and 12 
February 1944. 

Refugees returning to Naples, southern 
Italy, or Sicily presented a problem in the con- 
trol of the spread of the disease. They were 
deloused before being permitted to enter and 
all persons were required to present a certifi- 
cate of a recent delousing before being per- 
mitted to leave the city. Vaccination played a 
very minor role in the control program among 
the civilians ; only about 45,000 of the first of 
the series of three injections were given. Later 
all civilians were inoculated; 2h cc. of the vac- 
cine being given in 1 dose. 

Only two cases occurred in United States 
military personnel : one was a vaccinated man 
from the Fifth U. S. Army and one was an 
unvaccinated man. Credit for the low incidence 
was due in part to the vaccination program of 
the U. S. Armed Forces and to the higher 
standards of personal cleanliness among the 


Louse-borne relapsing fever occurred in an 
Italian prisoner of war in July 1943 in a pris- 
oner of war camp in Tunisia. For the next few 
months a few sporadic cases were reported by 
the French among both European and x\rabian 
civilians, but there was no indication of seri- 
ous epidemic tendencies. Eight cases were re- 
ported in January 1944, 51 in February, 250 
in March, and from then on there was a 
monthly rise until a peak of 6,536 new cases 
were reported in March 1945, after which the 
incidence receded. A total of 41,755 cases were 
reported during 15 months in Tunisia and this 
was considered to be approximately one-fifth 

the actual number, taking into account 
known cases among the Arabs. 

A U. S. Navy epidemiological unit was af 
forded the opportunity of studying the e 
demic at close quarters and to assist th' 
French health authorities in their efforts to 
control the disease. They closely observed the 
cases that occurred in two small Arab villag^^ 
near a United States naval station. The mea^ 
age of the inhabitants of these villages w^s 
24.7 years and the mean age of the patients 
was 22.6 years. The signs and symptoms of thg 
disease were quite uniform in all patients, con. 
sisting of fever, headache, generalized malaise 
chills, nosebleed, abdominal pain, and occas' 
sionally, vomiting. The majority of the patients 
showed a generalized petechial rash on the 
arms, chest, and abdomen and an enlarged 
spleen. The rash appeared early in the disease 
as small, bright red areas that faded to brown 
after 2 days and disappeared in about 5 days. 
Leukocyte counts were inconclusive. Twenty 
percent of the patients showed a slight neu- 
trophilic leukocytosis, 20 percent had leuko- 
penia with a relative lymphocytosis and, 60 
percent had normal white blood cell counts 
throughout the course of the disease. Blood in 
all cases was positive for spirochetes in stained 
smears as well as in darkfield examinations. 
Agglutination tests with Proteus OX-19 ani 
gen was negative in all cases, both during 
course of the disease and after convalescence, 
thus ruling out a concurrent typhus fever in^ 
fection. w 

No cases occurred among United States 
military personnel. The effectiveness of DDT 
against the insect vectors and the therapeutic 
value of penicillin was also studied. Fifty out 
of fifty-six persons examined during a prelimi- 
nary louse survey had body lice and nits. The 
entire population was dusted with 10 percent 
DDT in talc. Following this, 9 new cases oc- 
curred within the next 9 days (the normal in- 
cubation period of the disease). No further 
cases occurred in these villages after that time. 
A second louse survey held at the end of the 
incubation period revealed no lice or nits. 
Twenty-seven patients with the disease were 
treated with penicillin. Adults were given 30,- 
000 units intramuscularly every 3 hours for 





48 hours. Children were ^iven 20,000 units at 
|.}^e same intervals and for the same period of 
time. All positive blood smears became nega- 
tive within 48 hours following- which there was 
a rapid clinical recovery and no relapses. 


Bubonic plague is sporadic throughout the 
Mediterranean but major outbreaks of the 
disease have been very rare. The exact inci- 
dence and the mortality rate were not re- 
ported to the Navy, but unconfirmed reports 
were that about 30 cases occurred and that 
the mortality rate w^as 40 percent. Ferryville 
was the site of a U. S. Navy LCT base and, 
at the time of an outbreak of plague there, had 
a complement of 80 officers and men. They 
were promptly vaccinated with formalin- 
killed vaccine containing 2,000 million organ- 
isms per cc, by two injections at 5-day inter- 
vals, the fii'st, one-half cc. and the second 1 cc. 
During the 4 months immediately preceding 
the appearance of the disease, 190 rats were 
trapped by the Navy medical staff beneath the 
quonset huts of the base, in the galley, under 
tent floors, and along the sea wall. All were 
autopsied and none were found to be infected. 

A U. S. Navy team assisted the French 
health authorities in rat extermination in 
Ferryville after the outbreak of plague. A 
total of 37 rats were taken by trap or by 
poisoned baits during this period. They were 
of two types, the black house rat, Rattus rat- 
tus, and the wharf rat, Raftus aJcvaiuh'inns. 
The black rat predominated. Fleas found on 
live trapped rats were of three genera, the 
common rat flea, Xoiop.HyUa cheopsis, the hu- 
man flea, Pulex irritans, and the dog and cat 
fleas, Ctenocephalides canis and CtenocephaU 
ides fells. The greatest number of fleas found 
on one rat was 100, predominantly X, cheopsis. 
Three of the dead rats taken were positive for 
Pasteurella pestis. 

The Advanced Amphibious Training Base, 
Bizerte, was located about 10 miles from 
Ferryville. At the time of the plague outbreak 
in the latter place there were in excess of 
10,000 U. S. Navy personnel stationed there. 
All were given plague vaccine in the same 

manner as those in Ferryville. A strict quar- 
antine against entry into Ferryville, except on 
official business, was enforced on all United 
States military personnel. Rat extermination 
was intensified at the Bizerte base and 66 rats 
were caught. None was found to be infected. 
Traps and poisoned baits were used. The poi- 
sons used were barium carbonate, red squill, 
and thallium sulfate on ground beef, bacon, 
salmon, rolled oats, and whole wheat. Barium 
carbonate and red squill were found to be more 
effective than thallium sulfate. 

An attempt was made to employ the in- 
secticidal effect of DDT in the campaign 
againt the disease by the U. S. Navy team 
assisting the French. A 5 percent solution of 
DDT in kerosene was thoroughly sprayed by 
motor-driven apparatus over all vegetation, 
refuse, and rat infested areas in the hope of 
destroying fleas in that area. Unfortunately 
this phase of the work could not be followed 
through because of the exigencies of the serv- 
ice but it was believed promising and to war- 
rant use in similar circumstances. 

An outbreak of human plague occurred in 
Dakar, Senegal, French West Africa in April 
1944 and continued into the following Novem- 
ber. A total of 567 cases were recorded with 
514 deaths-a mortality rate of 91 percent. A 
total of 10,500 rats were taken during the 
course of the epidemic. Three thousand five 
hundred and one were examined for plague and 
65 were found to be infected. The rats taken 
consisted of the Norwegian rat (Rattus nor- 
v('gicus), the Alexandrine rat (Rattus aUxan- 
drini(s), the common black rat (Rattus rat- 
tus), and the Camtchouli rat (Crycetomys 
gambianus). The first three were common, the 
fourth somewhat less so. With a few excep- 

Table 26. — Types of plague cases seen in Dakar, and 
2Jej'cent mortality 





Number in native 






Number in military 






Percent mortality — 


native hospital 



Percent mortality — 


militaiy hospital 





tions the infections were found to be limited 
to the Norwegian and Alexandrian rats. 

Statistical data are available on 127 cases 
treated in the Native Hospital and on 17 cases 
treated in the French Military Hospital (table 

Both hospitals employed the same treatment 
and therapeutic agents but in a slightly dif- 
ferent manner, as shown in table 27. 

Table 27. — Methods of treatment of plague cases 

Therapeutic agent 

Native hospital 

Military hospit-al 

Sulfapyridine _ _ 

4-6 gm, daily as long 
as fever continued. 

8 gm. daily for 3-4 days 
orally and intrave- 
nously then 3 ^ni. 
daily as lorij; as fever 
eon< inued. 

6 gm. daily as long as 
fever persisted. 

2-3 e.<'. first dav then 1 
ce. .hiily as'lr.nir as 
fever jx'rsisted. (liven 
intrab\ibo in bubonic 
type and subcutane- 
ously ill septicemic 

Sulfadiazine . _ 

Initial dose, 1^ KHi., 
then 1 urn. every 4 
hours for duration 
of fever. 

1 ee. intravenously as 
loriK as fever per- 

Plague l)acteriophage._ . 

Plaifuo anti.seruin 

(Madagascar .st^ain^ 

100 cc. daily during 

60 SO fc. flail\- intrave- 
nously during fever. 

Sulfapyridine was considered ineifective and 

was discontinued as soon as a sufficient supply 
of sulfadiazine became available. The results 
of treatment are shown in table 28. Those cases 
at the Native Hospital w^hich were treated 
with sulfapyridine are omitted because data 
on them is not available. 

It was the opinion of the medical officers in 

both hospitals that bacteriophage was indis- 
pensable and that the best results were ob- 
tained from the combined use of bacteriophage 
and sulfadiazine. There was a 100 percent 
mortality among the septicemic and pneumonic 
cases, regardless of the therapy used. The pa- 
tient with the bubonic type of case had very 
little chance of survival unless treatment was 
started before the fourth or fifth day of the 

An extensive program of flea eradication 
was undertaken in an effort to destroy the 
insect vectors. The inhabitants of the flea-in- 
fested area and their habitations were treated 
with DDT. The effort was 90 to 95 percent 
effective in killing the insects. 

Table 28. — Results of treatment of plague 

















Sulfadiazine and bac- 


teriophage. _ 
















Scrum and 8ulfapyri- 






Serum and sulfapyri- 


dine and bacterio- 

phaf2:c ^ 






Sulfapyridi nr and 









SiTurii and l)acterio- 

phaKc . 







Serum and sidfadia- 

zine and bacterio- 


Sulfadiazine and bac- 





















Yellow fever is not found in French North 
Africa, nor in any of the countries or islands 
of the western Mediterranean region. No cases 
were reported among United States military 
personnel and no measures, except routine vac- 
cination, were necessary. 


Schistosomiasis is not prevalent in North 
Africa. One case of the disease was reported 
among United States naval personnel in the 
theater. The source of his infection could not 
be determined. A survey of all the fresh water 
streams in the vicinity of his ship failed to 
reveal any evidence of cercariae. Surveys were 
conducted at the other Navy bases with similar 
negative results. 


Amebic dysentery was endemic in the Medi- 
terranean countries but did not constitute a 
serious health menace. 


Infectious hepatitis was the most trouble- 
some disease condition throughout the entire 



theater. The local health authorities in all areas 
^ere in agreement that the disease did not 
exist in the Mediterranean region before 1943, 
hence it cannot be attributed to any local con- 
dition, but was a by-product of the war. A few 
sporadic cases of what was diagnosed and 
treated as simple infectious jaundice occurred 
during the first months of the campaign, al- 
though in no greater number than was experi- 
enced among the Armed Forces in the United 
States and Great Britain, and they responded 
to the usual treatment in a normal time. A 
more severe type of the disease appeared 
among the forces in Tunisia in eJune 1943 and 
gradually increased to epidemic proportions 
during the summer and autumn. When cooler 
weather began the incidence declined but the 
disease did not disappear. It appeared among 
the forces in Italy and during the winter of 
1944-45 became so widespread that the prob- 
lem was considered serious. 

In the earlier cases in Tunisia the onset was 
usually insidious with malaise, fever, and 
anorexia. In a few days nausea, vomiting, 
right upper quadrant discomfort, liver enlarge- 
ment, and usually a mild diarrhea appeared. 
The amount of fever bore no relationship to 
the severity of the disease. Some degree of 
jaundice was usually apparent after the fifth 
day, although some patients never became 
icteric. Others had an icterus index as high as 

200, The degree of jaundice had little or no 
relationship to the severity of the disease or to 
the length of convalescence. Liver tenderness 
and liver enlargement were constant physical 
findings. Slight leukopenia was the rule al- 
though in many patients the white and differ- 
ential blood cell counts were normal. Red blood 
cell counts and hemoglobin showed no altera- 
tion. About 10 percent of the patients had an 
acute stormy onset with fever, chills, nausea, 
vomiting, and mild prostration. 

Relapses after apparent recovery became 
more frequent during the latter part of the 
Tunisian outbreak. This appeared to indicate 
that the etiological agent was increasing in 
virulence as time went on. The mortality rate 
was 0.05 percent. At necropsy acute yellow 
atrophy of the liver was noted. 

The fact that the disease made its appear- 
ance in the early summer and continued during 
the warm months, to decline in incidence with 
the advent of cooler weather led to the belief 
that it was associated with the acute gastro- 
intestinal infections that were also prevalent 
during that period. All attempts, however, to 
identify and isolate the exact etiological agent 
were futile. Blood studies were negative for 
Leptospira icterohaemorrhagiae and other 
spirillae. All attempts to cultivate a virus from 
blood, urine, and feces of patients with the 
disease were failures. 

Chapter IX 

Air Evacuation and Transportation 
of Sick and Wounded 

Leon D. Carson, Capfain (MC) USN 
Norman Lee Barr, Commander (fAC) USN 

Before the beginning of World War II the 
Bureau of Medicine and Surgery, in conjunc- 
tion with the Bureau of Aeronautics, made 
provisions for procuring specially fitted and 
constructed ambulance planes to evacuate the 
sick and wounded. Until well after the war 
began, aerial transportation of the sick and 
injured was a function of local commands, but 
the early experiences in the Guadalcanal cam- 
paign highlighted the need for an aerial evacu- 
ation service that could be coordinated by one 
central agency. At Guadalcanal, it was again 
indicated that three cardinal factors operated 
to reduce the mortality from wounds. These 
were : 

1. Immediate first-aid treatment. 

2. Prompt treatment of shock by the ad- 
ministration of plasma and morphine, the con- 
trol of hemorrhage, and the use of chemo- 
therapy as prophylaxis against infection. 

3. The earliest possible evacuation of the 
wounded to hospital ships or advanced base 
hospitals for definitive treatment. 

The United States was not alone in de- 
veloping facilities for the transportation of 
casualties by air. In the first years of the 
European phase of World War II, the armies 
of Britain, Russia, and Germany developed 
and employed air transportation for the sick 
and wounded. In Russia and particularly in 
Germany, this service developed rapidly. These 
developments were closely observed by the air 
medical services of our Army and Navy, who 
began to plan methods of evacuation and de- 
vise medical equipment transport aircraft. 

Air evacuation of the sick and wounded on 
a large scale had its inception in the Pacific 

during the Battle of Guadalcanal, when the 
advance echelon of Marine Air Group 25, con- 
sisting of 14 R4D2 aircraft, arrived in the 
South Pacific on 1 September 1942. They made 
the first flight into the combat zone 2 days 
later. Evacuation of the wounded was started 
immediately, although no medical personnel 
were available for the planes. The planes were 
equipped with supports for 18 stretchers, but 
the auxiliary gas tanks in the cabin, needed 
for long trips over water, prevented the in- 
stallation of more than 10 stretchers. During 
the first 6 weeks, there w^as no medical super- 
vision of loading of casualties, or facilities for 
the handling of patients at unloading terminals. 
Medical personnel were added to crews of 
planes carrying the more seriously wounded 
early in 1942. By 1 November 1942, a suffi- 
cient number of medical personnel were avail- 
able to permit medical officers to accompany 
planes carrying the seriously w^ounded. Hos- 
pital corpsmen were assigned to air transports 
carrying the less seriously wounded and the 

Responsibility for air evacuation of combat 

casualties during these operations was divided 
between task force commanders in assault 
areas and the Commander, Forward Area, 
invariably resulting in delays in getting the 
wounded to hospitals. This division of respon- 
sibility was continued during the Pacific oper- 
ations, until the Air Evacuation Service was 
established under the administrative control of 
the Chief of the Bureau of Medicine and Sur- 

The foundation for a joint transportation 
service was laid in October 1942, when Army 


transport planes began joint operations with 
Marine Air Group 25 in the South Pacific. 
They provided transport service to Sydney in 
Australia, Auckland in New Zealand, Espiritu 
Santo, and Guadalcanal (by November 1942) 
and evacuated 4,595 casualties during the 4- 
month period ending December 1942. Patients 
were flown out of the combat area, usually 
loading under cover of darkness and often 
tinder enemy shell fire and bombing. 

At first no medical oflicer or Hospital Corps 
personnel were available for the screening of 
patients at the target area or to accompany 
the injured. Before long, however, a General 
Order issued by the wing commander required 
that (a) the hospital receiving units establish 
facilities and assign medical personnel for the 
reception of patients at airports, (6) medical 
officers and hospital corpsmen accompany pa- 
tients on aircraft whenever such personnel 
could be made available, and (c) receiving 
units provide transportation from the airports 
to the hospitals concerned. This order required 
that an air evacuation flight log be kept, and 
that liaison Hospital Corps personnel at each 
receiving airport insure the exchange of medi- 
cal equipment. In order to maintain contact 
between the operations office and receiving hos- 
pital, records were to be kept of all patients 
received at unloading terminals. A flight sur- 
Sfeon was detailed as loading officer at pickup 
points within the combat zone. By March 1943 
the South Pacific Combat Air Transport, com- 
posed of Army, Navy, and Marine air evacu- 
ation groups, was an efficient and effective or- 
ganization. It transported 12,017 patients from 
Guadalcanal during the period from Septem- 
ber 1942 through June 1943. 

The following conclusions were reached re- 
garding the safety of transporting casualties by 
aircraft: (a) Any patient may be evacuated 
by air if he is in condition to travel at all. 
(b) Patients suffering from chest, abdominal, 
or other severe wounds should be free from 
shock, (c) Patients who have undergone an 
abdominal or other serious operation should 
have recovered from postoperative shock. 
(d) Patients with acute chest and abdominal 
injuries should be flow^n at low altitudes, (e) 
The three most valuable therapeutic aids for 


use on planes are morphine, plasma, 
oxygen. (/) The general condition of the 
tient is more important than the exact natuj.^ 
of his disease or injury. 

Experience of medical personnel associate^ 
with these operations indicated the need fo^ 
a medical officer to be in charge of the selec. 
tion and loading of patients for air evacuation 
and for a trained nurse and Hospital Corps 
personnel to accompany patients in flight. 

In most campaigns, the operations plan as- 
signed no responsibility to any organized 
transport squadrons for the evacuation of 
combat wounded and sick; this task was as- 
signed to hospital ships and surface craft. On 
those occasions when air transport was called 
upon to clear a combat area of wounded, it was 
done as an emergency measure and without 
profiting from the lessons learned in the earlier 
days in the Solomons. An example of un- 
planned air transport evacuation of casualties 
occurred at Saipan, where it is estimated that 
aircraft provided 15 percent of the lift for the 
wounded and sick. No provision for proper 
medical screening of patients was made and 
the Air Transport called in to lift patients had 
no medical or nursing personnel or necessary 
equipment. As a result, a number of wounded 
died en route to hospitals in Hawaii, or arrived 
in poor condition. This is in contrast with the 
planned air evacuation program at Iwo Jima, 
where about 2,500 wounded were evacuated by 
air to hospitals in Guam and Saipan without 
the loss of a single patient aboard the air 
transports; or with Okinawa where 16,100 
were carried by hospital ships, 4,900 by other 
ships, and 15,700 by Air Transport. Of the 
15,700 transported by NATS or ATC hospital 
planes to Guam or Saipan, only 3 patients died 
en route. 

The geographical distribution of anticipated 
areas of operation indicated the need for an 
even broader organization to cover the air 
evacuation program. On 24 November 1942 
the Division of Aviation Medicine and the 
Chief of Plans and Training Division, Air 
Surgeon's Office, discussed plans to develop a 
coordinated evacuation of patients by air, but 
the lack of facilities, including airplanes and 
personnel, prohibited the development of » 



nipletely adequate plan at that time. Coordi- 

tion and control of the Air Evacuation Serv- 
. j«emained a function of task force and area 
commanders until October 1944. At that time, 

the basis of a study made by the Division 
of Aviation Medicine, recommendations v^ere 
made for the establishment of an air evacua- 
tion command whose primary mission v^ould 
5e evacuation of casualties and to which would 
be assigned experienced flight surgeons, spe- 
cially trained nurses and flight hospital corps- 
men. Planes of the latest type were to be so 
modified as to equip them for proper handling 
of casualties. This command, established under 
ComAirPac, was designated as Air-Sea Rescue 
and Air Evacuation Squadrons. It was intended 
that it should function in the dual capacity of 
rescue and air transportation. Later it became 
known as the Dumbo Squadron. Its activities 
were limited to air-sea rescue, principally 
because of the range of the planes that were 
used. Combat operations were developing rap- 
idly in the Pacific at increasing distances from 
established hospital facilities. The problem of 
moving large numbers of casualties from target 
areas to advanced hospitals was becoming 
immediate and pressing. Although hospital 
ships and other types of hospital transporta- 
tion were constantly being placed in commis- 
sion, they still were not capable of carrying 
the peak loads that occurred. 

Because of a lack of four-engine long-range 
aircraft, the function of air evacuation was 
transferred at the request of Division of Avia- 
tion Medicine to the Naval Air Transport 
Service. The VE squadrons organized under 
this plan were first used in combat in the 
battle of Saipan. 

Reports of the work of Air Evacuation 
Group One in the Central Pacific Theater dur- 
ing the bitter struggles for the capture of the 
two final objectives in Japanese home waters 
attest the effectiveness of that command's 
operations. The extensive use made of air 
evacuation at Okinawa has no parallel in 
previous amphibious operations. Air evacuation 
Was regarded as remarkably successful and 
Was uninterrupted on all but 2 days of the 
operation. The heavier load was carried by 
planes of NATS Air Evacuation Group One, 

ATC planes lifting roughly a third of total 
patients carried by air. The success of this 
transport operation can be attributed largely 
to the highly trained personnel of both organ- 
izations and to careful medical screening of 
patients at the target area. 

From experience gained in the South and 
Central Pacific, as well as in the European 
Theater, an operational plan for air evacuation 
and a training schedule for medical, nursing, 
and Hospital Corps personnel were formulated 
and placed in operation within the Pacific 
Theater. Flight nurses and flight hospital corps- 
men were placed under instruction at a newly 
established school for Air Evacuation at Naval 
Air Station, Alameda, Calif. The course con- 
sisted of didactic lectures and demonstrations 
in techniques employed, survival training, minor 
surgery, and first aid. Emphasis was placed 
on recognition and treatment of shock, splint- 
ing and redressing of wounds, and chemother- 
apy. Graduates of this school were made avail- 
able to the Air Evacuation Wing. 

Air Transport Evacuation Group 94.12 was 
supplied with trained flight nurses, flight hos- 
pital corpsmen, and medical officers in sufficient 
number to provide not only adequate medical 
and nursing supervision of casualties, but also 
a medical screening team at target area to 
insure proper selection of patients for air 

After the conclusion of the Iwo Jima opera- 
tion, the total responsibility for air evacuation 
of noneffective sick and wounded. Pacific Ocean 
Areas, was assumed as a function of Com- 
NATSPac, and Air Evacuation Group One 
was set up at Guam. 

Air Evacuation Group One included the fol- 
lowing personnel: 1 captain MC, USN, staff 
medical oflScer; 5 flight surgeons, lieutenant 
commander MC, USN and USNR; 1 flight sur- 
geon, lieutenant MC, USNR ; 4 Hospital Corps 
oflficers; 85 flight nurses; 5 chief nurses, 
lieutenant NC, lieutenant (jg) NC, and ensign 
NC ; 156 flight hospital corpsmen. 


During the Okinawa operations, R5D-l's, 
and 3's — the Douglas Skymasters — were em- 
ployed. These are four-engine land planes em- 



ployed by both ATC and NATS for long- 
distance cargo and passenger hauling. Those 
assigned to the air evacuation schedules were 
equipped with standard webbing strap litter 
supports for carrying 28 litter-borne patients. 
Additional seats for four ambulatory patients 
were also provided. In addition to the regular 
crew, a flight nurse and a flight hospital corps- 
man accompanied each trip. Medical equipment 
and supplies comprised the following items : 

1. One airborne medical chest, weighing 
about 70 pounds and containing dressings, 
instruments, medicines, bedpans, urinals, and 

2. One refrigerated whole blood shipping 
container modified to contain two units each 
of whole blood, plasma, serum albumin, and a 
supply of distilled water and penicillin. 

3. Boxed evacuation flight rations, which 
were placed aboard each plane just before 
departure to target, and consisted of canned 
fruit juices, soups and boullions, crackers, 
candy, tomato juices, tinned boned chicken, 
turkey, tuna, chewing gum, cigarettes, and 
other miscellany. In addition, a carton contain- 
ing bread, paper cups and feeding tubes, and 
thermos jugs containing hot coffee and water 
were carried. The fresh water tanks of the 
plane were also filled before each trip. Two 
electric hot cups (12-24 volt) were carried in 
the medical chest. 

4. Twenty-eight steel pole or aluminum pole 
litters, as well as three blankets per patient. 
These were off-loaded at target in exchange for 
loaded litters and blankets. 


All patients at target area were routed 
through an air evacuation hospital situated 
about a mile and three-quarters from loading 
point on air strip. Emergency surgical treat- 
ment and redressings were accomplished there. 
At the air strip, all patients were screened by 
a combined Army and Navy screening team 
prior to departure. This team issued treatment 
orders to flight nurses in charge of each plane 
load regarding chemotherapy and blood substi- 
tutes for care of the patients en route to the 

Marianas. Patients were loaded aboard air 
planes within a half hour after they landed at 
target air strip. Loading was accomplished by 
two-stage loading platforms on wheels, or by 
finger-lift trucks. Planes arrived and departed 
on half -hour schedules beginning at 0700. 

After a 1,500-mile return flight of about 
7/2 hours' duration, patients were disembarked 
at the Air Evacuation Center in Guam. Un- 
loading of ambulatory cases was by roll-awav 
two-stage loading platform, or by finger-lift 
truck. Planes taxied to a paved area imme- 
diately outside the entrance to the Air Evacua- 
tion Center at Agana. 

All litter patients were carried into the Air 
Evacuation Center and litters placed on slightly, 
inclined racks so that the head of each litter 
was elevated about 6 inches. Patients were 
examined by medical officers and nurses, and 
displaced dressings were secured or replaced. 
Those in shock were given plasma or whole 
blood, and emergency transfer to nearest Navy 
or Army hospital was arranged. All other 
stretcher patients were loaded into ambulances 
for dispatch to hospitals. Ambulatory patients 
were sent in busses. 

Most of the rearward movement of patients 
was performed by surface ships, but a large 
numl)er of patients were returned via Naval 
Transport Service and ATC. Between 2,40^ 
and 2,500 patients per month, noneffective siSP 
and casualties were transported by air from 
Guam to Honolulu, and about 15,000 patients 
per month were moved from Honolulu to Oak- 


In evacuation of casualties from combat to 

target areas, military necessity required the 
transfer by air of almost every conceivable 
type of casualty. Patients having chest wounds 
with pneumothorax, severe abdominal wounds 
with extensive visceral damage, spinal injuries 
with partial paralysis affecting accessory 
muscles of respiration, severe head wounds 
with exposure of brain tissue, and many other 
serious wounds have been transported by air. 
The only criterion as to acceptance by medical 
screening officers at the target has been the 
question, "Is the patient sufficiently recovered 



from primary or postoperative shock or has 
jiemorrhage been so combated, as to permit 
travel by any means of transportation?'' Special 
flights at lov^ level v^ere arranged for patients 
;vhenever requested by the flight nurse, and as 
a consequence patients required administration 
of oxygen only infrequently. Each plane carried 
three portable oxygen supply systems. Very 
few patients had delayed shock v^hile in transit. 
Nurses w^ere instructed in the treatment of 
shock in its incipient stages and the routine 
use of plasma and serum albumin v^as directed. 


Selection of patients for evacuation from 
hospitals in the Marianas to Honolulu or the 
mainland v^as made, in collaboration w^ith the 
medical, surgical, and neuropsychiatric serv- 
ices of those hospitals, by tv^o flight surgeon 
screening officers attached to Air Evacuation 
Group One. 

Patients v^ith peripheral nerve injuries and 
those with brain or severe head injury w^ere 
given top priority for evacuation to the States. 
Psychotics v^ere carefully prepared and sedated 
prior to departure. 

At first, due to lack of a holding center at 
Honolulu, all patients arriving there were 
readmitted to hospitals in that area. Later, pro- 
vision was made for a holding center where 
patients scheduled for transportation to the 
States could rest for 24 hours or overnight, 
before continuing flight. This permitted an 
opportunity for careful changing of dressings, 
bathing, and other hospital care of patients. 


1. Morale. — The improved spirits and out- 
look of patients brought in by air was remark- 
able. The usual comment of patients was either : 
''How long has this been going on?'' or ''Why 
hasn't the Navy done this before?" This morale 
effect extended to combat troops who knew 
that, if wounded, they had a chance of speedy 
I'emoval from combat to quiet areas. 

2. Flexibility, — As compared with the hos- 
pital ship, air transport can adapt its schedules 

258015—53 15 

from day to day to adjust to increased or 
decreased casualty loads in combat areas. 
Further, patients arrive at forward area hos- 
pitals on an hourly or half -hourly schedule in 
small increments, and this prevents the sudden 
overloading of all available ambulances and 
busses, which occurs when hospital ships arrive. 

3. Economy of Medical Personnel. — An 
equivalent number of patients can be handled 
from point of loading to destination with one- 
tenth the medical, nurse, and Hospital Corps 
personnel required for evacuation by hospital 
ship. As an example, one hospital ship could 
make a round trip between Okinawa and Guam 
in 8 to 10 days, bringing about 600 patients. 
Two R5D planes could evacuate 640 patients 
in 10 days and employ only 6 flight nurses and 
6 hospital corpsmen, allowing each nurse and 
hospital corpsman 2 days' rest between trips. 
If aircraft were designed to carry a passenger 
load equivalent to maximum cargo carrying 
tonnage, well over 60 passengers could be 
carried per plane. 


1. Patients cannot be evacuated from a target 
area until an air strip has been captured and 
made ready. This period is variable ; experience 
showed that from 7 to 10 days are usually 
required. During this time hospital ships and 
auxiliaries, such as LST(H)'s, must carry on 
whatever evacuation is possible from the 

2. Transport aircraft cannot use air fields 
while they are under enemy air attack. How- 
ever, hospital ships and LST's are similarly 
handicapped when the fleet lying off shore is 
under such attack. 

3. Transport aircraft have not been designed 
for carrying wounded. All have to undergo 
modification before being assigned to this task. 
Space for litters does not permit the carrying 
of enough patients to even approach weight- 
load capacity. 

Maximum use should be made of air trans- 
port to transfer sick and wounded personnel. 
Plans for all future operations should specify 
a task for Air Evacuation Service commensu- 



rate with its capacity. Under no circumstances 
should air evacuation be considered as an 
auxiliary or secondary service. 

Military transport aircraft should be de- 
signed to permit maximum litter capacity. A 
lighter weight, stronger medical chest should 
be developed which, when opened, can be sup- 
ported at a convenient working level. Instruc- 
tion in the techniques and methods of evacuat- 

ing patients by air should be included in the 
curriculum at Schools of Aviation Medicine 
Cognizant Bureaus should jointly develop pi^j^ 
and specifications for transport aircraft for ai^ 
evacuation. Food systems should be investi. 
gated to determine which are the best types of 
diets for sick and wounded that can be pre, 
pared and served on evacuation aircraft 
combat areas. 


Chapter X 

Aviation Medicine 

A. Developments in Aviation Medicine 

John C. Adams, Rear Admiral (MC) USN (Retired) 

To appreciate the significance of aviation 
medicine and its value in World War II, its 
record of accomplishment must be viewed 
against the background of meager facilities and 
scarcity of personnel that existed prior to the 
national emergency. Such a perspective reveals 
the degree of our unpreparedness. These defi- 
ciencies, however, were largely a reflection of 
the general situation that then confronted naval 
aviation as a whole. Regardless of the valiant 
efforts for progress in the naval air arm, and 
the many noteworthy achievements, the fact 
remains that naval aviation then lacked the 
green light for healthy growth and develop- 

It was not until the Germans had demon- 
strated the importance of aviation in the war in 
Europe that a new perspective in aviation was 
forced upon us. These revelations, though much 
belated, were profound and decisive, and cleared 
the way for a modern and gigantic Army and 
Navy air force with the attendant development 
of aviation medicine. 

Prior to the declaration of the national emer- 
gency, the Division of Aviation Medicine in the 
Bureau of Medicine and Surgery consisted of 
one medical officer and one clerk. Approximately 
49 flight surgeons were on duty with aviation 
commands aiShore and afloat. Their principal 
function w^as to determine the physical quali- 
fications for flying of some 3,000 aviation per- 
sonnel. There was no Navy school to train 
flight surgeons. Funds or facilities for aviation 
medical research did not exist, nor were flight 
surgeons engaged in research. 

The program necessary for a healthy aviation 
medical service required, among many other 

things, improvement of the low morale and 
service standing of flight surgeons. A school 
of aviation medicine was required, and a pro- 
gram for aviation medical research and facili- 
ties for its accomplishment were urgently 
needed. Later there would arise the need for 
scientists allied to medicine ; the psychologists, 
the physiologists, and others. 

With these objectives in mind, this small 
organization of flight surgeons in 1938-39 was 
progressively expanded until, at the close of 
the war, the aviation medical service had over 
1,200 medical officers. It staffed an aircraft 
carrier program that involved over 100 ships, 
and provided the medical service for all Marine 
Corps aviation units ill the Pacific. It rendered 
service from Guadalcanal to the Aleutians. The 
record of the heroic service of the flight surgeon 
is attested by the fact that the death rate of 
flight surgeons was 2/^ times greater than that 
of any other group of naval medical ofl&cers 
in the combat area. 

In 1939 a limited number of flight surgeons 
were assigned to flying duty. This proved to be 
a great factor in increasing the proficiency and 
effectiveness with which they performed their 
duties. After the declaration of war, increasing 
numbers of aviation medical examiners and 
flight surgeons were given flight orders, until 
at the close of the war the majority of such 
officers were flying regularly. 

To improve further the efficiency of flight 
surgeons, authority was obtained from the 
Bureau of Aeronautics in 1938-39 to give 
flight training to 4 flight surgeons each year 
and to give them the designation of naval 
aviator. Medical officers selected for this train- 



indicate the reasons for their choices on a 
^hecklist prepared from the free responses of 
previous respondents. 

Two conditions were responsible for the suc- 
^gss of the technique. Wherever possible, the 
H(S) officers lived v^ith the squadron and got 
to know its members on an informal basis, so 
that the actual request for their help, although 
officially sanctioned, did not come from a total 
stranger or through impersonal channels. The 
investip:ators were also supported by an official 
guarantee that the pilot's opinions would be 
treated confidentially and would be used for 
^•esearch alone. Inspection of the preliminary 
free response materials and analyses of the 
nominations gathered in the major project left 
no doubt that the pilots had cooperated in a 
most satisfactory manner. 

There were other developments of this com- 
bat criterion project carried on by the Wash- 
ington group. Representatives tried out the 
nominating technique at a preflight school to 
determine w^hether those characteristics men- 
tioned by combat aviators which did not refer 
to pilot skill could be indentified early in train- 
ing. The results suggested that attributes like 
leadership and teamwork could be judged by 
fellow cadets, although there was no guaran- 
tee that these judgments would agree with 
those made when these men reached opera- 
tional flying. In another study, the extreme 
groups identified by the nominations of combat 
pilots were compared in terms of their athletic 
records, as a corollary to the basic research on 
the validity of test scores, age, and other pos- 
sible predictors of combat proficiency. These 
subsidiary investigations, carried out at the 
request of another Bureau, illustrate the serv- 
ice function of the Aviation Psychology Branch 
and indicate that administrative boundaries 
did not restrict its areas of usefulness. 

In addition to the validation of field work 
and the development and standardization of 
new tests, the Central group had administra- 
tive functions. It exchanged information with 
the Army Air Forces testing program so that 
each psychological service could benefit from 
the work of the other. The section checked the 
accuracy of scoring done in the field and main- 
tained card files for record and research pur- 

poses. Statistical breakdowns of attrition data 
gave the frequency of various reasons for fail- 
ure as well as the relative ability of the tests 
to predict each type of failure. The different 
parts of the selection battery were correlated 
with age, education, previous flight training, 
and other relevant factors. It was the respon- 
sibility of the Aviation Psychology Branch to 
make such administrative recommendations as 
the results of these analyses warranted. 

The Selection and Procurement of Specialists 

By the summer of 1941 the demand for the 
procurement of Naval Pilot material had 
grown to such an extent that the medical ex- 
aminers sent appeals to the Navy Department 
for technical help. On 15 July 1941 the Chief 
of the Bureau of Aeronautics issued a directive 
stating that a new class of commissioned 
specialists was to be procured. In general, the 
duties of these specialists were to administer 
research projects under the jurisdiction of the 

In the initial stage of the program the psy- 
chologists were assigned the duty of adminis- 
tering, scoring, and reporting test scores, but 
their duties steadily increased to include a 
variety of services. The Selection Board psy- 
chologist played a part in the establishment of 
the procedures of the Selection Board. He took 
part in the procurement program. He prepared 
procurement addresses, radio scripts, and pub- 
licity materials. In some cases, the psycholo- 
gist took on the additional task of the terminal 
interview of those rejected. 

These officers also played a role in the in- 
structor-selection projects. After the institu- 
tion of a selection program based on this re- 
search, they carried out studies to check its 
effectiveness. Attrition figures were compiled 
and reasons why cadets were dropped or 
wanted to be dropped from training were 

The procedures at the various Selection 

Boards varied somewhat from time to time and 
place to place, but essentially were as follows : 
The applicant for flight training was checked 

for age, height, weight, and schooling. He was 
then given the Flight Physical Examination, 
a medical screening involving rigorous stand- 



ards of physical fitness. Having: passed this 
he was given the psychological tests. If his 
score met the standard, he was interviewed by 
a line officer who appraised his suitability for 
aviation training. 

As the pressure of procurement went up in 
the early part of 1942, the Bureau began to 
receive requests from the Selection Boards for 
the assignment of a second psychologist. 

The Field Service Specialist 

The Field Service Specialists w^ere psycholo- 
gists who were assigned to preflight schools, 
primary air stations, and naval flight prepara- 
tory and gunnery schools. Their chief duty 
w^s to administer tests and to assist in the 
development of the training program, but these 
officers proved to be useful in a variety of 
ways. One H(S) officer became a member of 
the Aviation Safety Board, another made con- 
tributions to the field of training for aircraft 
gunners. Many of them became student coun- 
selors or advisory officers to the cadets. More 
important, perhaps, were the contributions of 
these officers to experimental design and to 
statistical analysis of Naval Aviation data in 
the solution of flight training problems. 

The Special Services Officers 

The Washington group found themselves 
more and more in demand for help on specific 
problems outside their regular responsibilities. 
A battery of tests designed to select flight in- 
structors was established on the basis of re- 
search carried out by the central research 
group with the collaboration of the field serv- 
ice organization. The basic problem was the 
selection of valid criteria. The number of stu- 
dents completing training with each instructor 
was selected, but incomplete records and small 
numbers of cases made it inadequate. The 
composite criterion finally selected was based 
primarily on the rating of the instructor's per- 

E. Naval Aviation 

Compiled by Aviation Branch, Research 

Research in naval aviation medicine had 
been carried on for many years by personnel 
of the Medical Department, but these studies 

formance by his students, and secondarily 
the reports of inspectors who checked the wor]^ 
of each instructor. Using extreme groups, 
was possible to derive scoring keys which stood 
up under cross-validation. The validated meas. 
ures were not intelligence tests, but rather 
questionnaires regarding preference for assign, 
ments and attitudes tow^ards instruction. 

There were other problems in the fields of 
training. The group was asked to help select 
Link Trainer instructors, control tower oper, 
ators, and nonpilot navigators. An evaluation 
of the Link Synthetic Flight Trainers w^as made. 
The experimental design was set up by the 
Aviation Psychology Branch in conjunction 
with cognizant Navy Department officers, and 
one H(S) officer was assigned to the field sta- 
tion w^here the project was carried out. His 
responsibility was to set up the experimental 
and control groups, assist in compiling records, 
and watch for extraneous influences upon data. 
In a project requested by the Naval Air Train- 
ing Command, correlations were run between 
test scores and grades on specific flight ma- 
neuvers. They also were requested to set up 
and conduct an experiment to determine the 
relative value of two synthetic gunnery train- 

The Aviation Psychology Branch was called 
upon to apply quantitative methods to non- 
psychological problems. Thus a Bureau medical 
oflSicer enlisted help in making a statistical 
evaluation of the effectiveness of oxygen indoc- 
trination. They were also called upon to review 
the experimental design and the statistical 
treatment of data in a wide variety of reports 
reaching the Division. A member of the Wash- 
ington group was also assigned to the Office 
of Research and Inventions of the Navy De- 
partment. His function was to review the ex- 
perimental design for research proposals to be 
carried out under Navy contract. 

Medical Research 

Division, Bureau of Medicine and Surgery 

were not closely correlated with aviation. Ii^ 
November 1939 a Medical Research Section was 
established in the Bureau of Aeronautics. The 



liest problems studied by this activity con- 

^^^ned selection and training of personnel, 
^'^sual problems, and general problems of phys- 
• \ogy aviation. In December 1941 a group 
^^f psychologists and statisticians were added 
I the research staff to take over the super- 
vision of the studies in selection and training 
of aviation personnel. 

Another major development at this time was 
Ijie establishment of an altitude training pro- 
trram using low-pressure chambers, first at the 
Naval Air Station, Pensacola, Fla., and then at 
other naval air stations. The program entailed 
indoctrination of aviation personnel in the 
hazards of high-altitud« flying and protection 
against these hazards. 

Research in aviation medicine continued un- 
der the jurisdiction of the Bureau of Aeronau- 
tics until October 1942. At this time the staff 
of -psychologists was transferred to the Divi- 
sion of Aviation Medicine of the Bureau of 
Medicine and Surgery. Later the entire unit 
was incorporated into the Research Division, 
Bureau of Medicine and Surgery, as the Avia- 
tion Medicine Branch. The specific objective 
of this unit during World War II was to apply 
the results of research in medical problems in 
aviation to flight safety, flight etiiciency, and 
to increase the caliber of flight personnel 
through improved selection and training. 


The following activities conducted aviation 
medical research in the Navy: 

1. School of Aviation Medicine, NAS, Pensa- 
cola, Fla. 

2. Naval Medical Research Institute, Na- 
tional Naval Medical Center, Bethesda, 

3. Aero Medical Department, Naval Air 
Experimental Station, Naval Air Ma- 
terial Center, Philadelphia, Pa. 

4. Medical Field Research Laboratory, Camp 
Lejeune, N. C. 

5. Medical Research Department, U. S. Sub- 
marine Base, New London, Conn. 

6. Naval Air Training Bases, Corpus 
Christi, Tex. 

7. U. S. Naval Air Stations at San Diego, 
Calif.; Alameda, Calif.; Seattle, Wash.; 
Norfolk, Va. ; Quonset Point, R. I. ; Miami, 
Fla. ; Vero Beach, Fla. ; Jacksonville, Fla. ; 

and Anacostia, D. C. 

8. U. S. Marine Corps Air Station, Cherry 
Point, N. C. 

In addition, research of interest to the Navy 
was carried out at other naval activities as well 
as in Army and civilian laboratories. 


As early as 1932, Captain Poppen (then 
Lieutenant Commander) conducted studies on 
the effects of acceleration and on protective 
measures against these effects, in collaboration 
with the Fatigue Laboratory at Harvard. Sub- 
sequently, investigations were conducted at the 
naval aircraft factory in Philadelphia. Through 
experiments with dogs, a compression belt was 
devised to provide support to the abdominal 
area in order to prevent blood from pooling in 
the splanchnic vessels. In 1939 a complete air 
suit with provisions for compression of the 
splanchnic area and lower extremities was de- 
veloped and flis^ht tested, but was not found 
practical for service. In 1942 the Moeller-Car- 
son gradient pressure suit and the Ferwerda 
pulsatile-pressure suit were flight-tested at 
Anacostia and Cecil Field. These proved to be 
effective in preventing blackout and grayout 
in maneuvers, but they required improve- 

In 1943 gradient pressure suits were de- 
livered to combat squadrons for operational 
testing. Although pilots at first were enthusias- 
tic about the suits, it was later found that the 
suits were too cumbersome and impractical for 
general use. In 1944 extensive tests on the 
gradient pressure suits were conducted in the 
Pacilic. As a result a single-pressure suit was 
evolved from a modification of the old three- 
way gradient pressure suit. This suit was again 
modified by Moeller and Carson, was flight- 
tested at Eglin Field, Fla., and was adopted by 
the Army Air Forces, although the Navy still 
considered it too bulky for universal use. 


During the war it became necessary to de- 
velop a great number of items of clothing. 




particularly electrically heated clothing for the 
protection of naval aviators against cold. A 
very satisfactory summer flying suit, made of 
nylon, was developed. One feature of this suit 
that required investigation was the **inflam- 
mability'' of nylon fabric. It was determined 
at the Naval Medical Research Institute that 
nylon was a ''noninflammable" material that 
does not support combustion but reacts to heat 
only by melting. 

Fundamental work on body cooling during 
exposure to water at various temperatures 
added impetus to the development of a quick- 
donning antiexposure suit for use by airmen 
in the event that ditching at sea became neces- 
sary. The suit was developed jointly by repre- 
sentatives of the Naval Medical Research 
Institute; Research Division, Bureau of Medi- 
cine and Surgery ; Equipment and Materials 
Branch, Bureau of Aeronautics ; and Military 
Requirements Division, Bureau of Aeronau- 

The disadvantages of attempting to don an 
exposure suit in the critical moments of ditch- 
ing led to attempts to develop a suit appropri- 
ate for continuous wear, one permeable to 
w^ater vapor but impermeable to water. Such 
a suit was designed at the Naval Medical Re- 
search Institute but was not issued to the 

Other items of special protective clothing 
that were devised included body armor for 
protection against antiaircraft fragments. The 
Research Division, Bureau of Medicine and 
Surgery, designed and developed the aviator's 
nylon ' flak suit," and the "Doron" armored 
life jacket. 


In May 1943 the Naval Medical Research 
Institute i-epoi'ted the eff*ect of environmental 
conditions in flight on dental pulp and perios- 
teum. In their preliminary work, 115 fillings 
of various types were inserted into uniform 
cavities prepared in extracted human teeth and 
these teeth were placed in a pressure chamber 
having a simulated altitude of 60,000 feet for 
20 periods for 1 hour. No evidence of displace- 
ment of the filling following these exposures 
was noted, but it was believed that during 
rapid changes in altitude oral fluids might be 

forced under leaky fillings and so account fo^ 
the toothaches experienced by flying personnel 
In June 1944 rats were exposed at simulated 
altitudes of from 24,000 to 26,000 feet fo^ 
twenty-five 3-hour periods. That environment 
did not affect the rate of growth of the incisor 
teeth but did disturb the calcification of dentin 
Later in 1944 rats were exposed to vibration 
of 0.05 inches amplitude at 2,600 cycles pej. 
minute for twenty-eight 8-hour periods. This 
neither affected the rate of growth of incisor 
teeth nor the calcification of dentin. 

In March 1943 a study of the relationship 
of dental malocclusion to ear block showed that 
of 447 men with normal occlusion, 5.8 percent 
developed ear block, while in 374 men with 
some degree of malocclusion, 28.7 percent de- 
veloped ear block. Overbite, retrusion, and 
protrusion were the chief types of malocclu- 
sion. Of the various methods for clearing ear 
block, movement of the mandible proved to be 
the most effective. 

The Naval Air Station, Jacksonville, Fla., 
reported in March 1945 that mechanical pres- 
sure from expansion of air trapped under den- 
tal fillings was not the usual cause of dental 
pain occurring at high altitudes, and indicated 
that the pain in some way resulted from 
changes in barometric pressure associated with 
sudden variations in altitude. 

In July 1945 an extensive study of aerodon- 
talgia made at the Marine Corps Air Station, 
Quantico, Va., indicated that the pain of aero- 
dontalgia was often so severe that the person 
affected was distracted from performing im- 
portant tasks. They theorized that dental pain 
occurring during altitude changes resulted 
from referred pain from the maxillary sinus 
and could be relieved by techniques similar to 
those used for relieving aero-otitis media. 
Since there was a tendency for pain referred 
from the maxillary sinus to localize in carious 
teeth, good oral hygiene and regular dental 
examination for all aviation personnel was 
considered to be essential. 


The chief ear, nose, and throat problems in 

aviation medicine were acute aero-otitis media, 
aerosinusitis, and chronic deafness. Loss of 



,^y[nir in aviation personnel was prevented 
.jth the use or' various ear "defenders" ana 
^'wardens/ ^ particularly the V-51R. 

Techniques were evolved to reinfiate the 
iniddle ear after descent from high altitude. 
Vose clips to aid dive-bombing pilots in equal- 
izing middle ear pressures were suggested, but 
g^perienced pilots rejected these clips because 

the necessity of applying them just before 
the dive and removing the oxygen mask to do 
this. Inexperienced pilots who had formed no 
prejudiced conclusions about their equipment 
accepted these clips more readily, however. 



The study of the problem of feeding per- 
sonnel in flight resulted in the development of 
an emergency candy ration to be carried in 
the aviator's personal gear. This replaced such 
items as pemmican and high protein foods that 
were found to increase dehydration because of 
the resultant excretion of large quantities of 
water necessary for the dilution of the nitro- 
gen metabolites. 

At the University of Chicago and Columbia 
University altitude tolerance test studies 
showed the advantages of a high carbohydrate 
meal. Research was therefore directed chiefly 
toward the development of adequate in-flight 
feeding, providing hot food to replace choco- 
late bars and crackers. During the latter part 
of the war, some transport planes were 
equipped with apparatus for the preparation 
of complete meals. 


To provide an adequate supply of emergency 
drinking water in airplanes was always diffi- 
cult because of limited storage space and 
stringent weight fequirements. Zeolites for the 
desalination of sea water were introduced 
through the efforts of the Naval Medical Re- 
search Institute and the Permutit Company. A 
satisfactory desalination kit was devised and 
adopted for service use. To some extent the 
kit replaced canned water in seat packs. Final 
evaluation of the relative advantages and dis- 
advantages of the desalination kit and canned 
Water had yet to be made. Investigations were 

also conducted on the physiological action of 
the crystalloids remaining in sea water after 
use of the kit, of bacteria in sea water, and of 
standards for emergency drinking water sup- 

Most naval activities concerned with air-sea 
rescue problems also carried out tests with 
solar stills for sources of drinking water. 


Motion sickness was noted in approximately 
13 percent of aviation cadets. In rough air the 
incidence was 30 percent, while otherwise it 
was about 6.5 percent. Scopolamine hydrobro- 
mide, in doses of 0.6 mg. given 30 to 60 minutes 
before a flight, was found to be a preventive 
of air sickness and to have no undesirable side 
effects. The Naval Medical Research Institute 
found no undesirable side eflfects with scopola- 
mine-containing formulas but found them with 
bulbocapnine. Using a questionnaire technique, 
they found no evidence to indicate a correlation 
between general psychosomatic complaints and 
susceptibility to seasickness, although they 
considered such a questionnaire useful in 
screening out persons who would be severely 
affected by seasickness. 


In 1942 workers at the Experimental Diving 
Unit, Navy Yard, Washington, D. C, measured 
gaseous exchange under conditions simulating 
aviation and deep-sea diving. Inhalation of 
radioactive krypton was used to determine 
whether or not the rate of saturation of the 
tissues in the lower forearm and hand could be 
employed as an index of susceptibility to de- 
compression sickness. They found that this test 
could not be used to determine susceptibility 
to air embolism but that the technique gave a 
precise physiological index that might be used 
to estimate physical fitness. In 1943 these 
workers determined that preoxygenation and 
exercise substantially reduced the time re- 
quired for decompression. They confirmed pre- 
vious studies showing that susceptibility to 
decompression illness was influenced by alco- 
hol, disease, increasing age, and previous at- 
tacks. They noted further that after 1 hour of 
oxygenation at rest at sea level 88 percent 



of susceptible individuals when at 35,000 feet 
were protected from incapacitating symptoms 
of decompression sickness for 4 hours. 

In March 1944 the Naval Medical Research 
Institute reported that extravascular gas bub- 
bles occur in adipose tissues, in the adrenal 
cortex, and in nerve fibers, but not in the liver, 
skeletal muscles, or tendons; and were more 
numerous in those tissues rich in fat. A sig- 
nificant fall was observed in the specific grav- 
ity of the entire animal after decompression, 
this decrease being greater in fat animals than 
in lean ones. It was inversely related to the 
total fat content, but directly related to the 
water content. 

In January 1944 the Naval Medical Research 
Institute suggested a test for selection of per- 
sonnel resistant to the effects of decompres- 
sion. In the first procedure, in order to eliminate 
the most susceptible, the subject rested 1 hour 
and exercised 1 hour at simulated altitudes of 
38,000 feet. The second procedure provided 2 
hours of exercise at 38,000 feet. The most re- 
sistant men had no symptoms during this 

Pensacola reported in September 1945 that 
exercise at 26,000, 28,000, and 30,000 feet 
greatly increased the incidence of decompres- 
sion illness and that a greater incidence of 
decompression illness was encountered at 
higher temperatures than at lower tempera- 
tures. At altitudes below 30,000 feet for 20 
minutes, the incidence of decompression illness 
in resting subjects was very low and environ- 
mental temperature was not a factor. 


In September 1944 it was found that lights 

arranged so that at least 3 similar lights, 
widely separated, were visible from any angle, 
reduce the incidence of autokinesis. This ar- 
rangement was found to be advantageous in 
giving clues to depth perception. 

In February 1945 a group of workers ob- 
served that the autokinetic illusion was ex- 
perienced by persons who could not distinguish 
real from apparent motion. The recommenda- 
tion was made that aviators, and operators of 
other means of transportation, be taught the 
characteristics of the phenomenon and the 

practical means by which it may be reduce(j 
In November 1945 this group noted that the 
oculogyral illusion changes observed folio^^ 
ing stimulation of the semicircular canals 
were more easily produced in dim than ij^ 
bright illumination and were unaffected by the 
administration of relatively large doses of 
scopolamine hydrobromide. They considered 
the illusion to be of considerable importance 
in night flying. 

In March 1946 this same group developed 
a new device for checking the illusory percep- 
tion of movement caused by angular accelera- 
tion and by centrifugal force during flight. Ob- 
servations during various flying maneuvers 
were made in complete darkness, with a col- 
limated *\star'' installed in the rear cockpit of 
a training plane, and the observer's and pilot's 
reports were recorded during flight. They 
found that forces engendered by various flight 
maneuvers were sutticient to produce consider- 
able illusory perceptions of movement and dis- 
placement of an objectively motionless object 
observed in the dark. These illusions probably 
contributed to disorientation and resulted in 
accidents in night flying. 

The Naval Air Station, Anacostia, in a study 
on disorientation of pilots in night and instru- 
ment flying, found that 1,400 hours of flight 
experience was the dividing line in the indica- 
tion of "spinners" and "nonspinners." They 
believed that this degree of experience brought 
about suflBcient familiarity with disorientation 
problems so that they could be solved in flight 


In procedures for the measurement of alti- 
tude tolerance, it was noted that the dotting 
apparatus was useful in obtaining a quantita- 
tive distinction between normal and severe 
anoxia, but that it was unsatisfactory in the 
detection of moderate degrees of anoxia. No 
deviation from the base line results were ob- 
tained at simulated altitudes of from 8,000 to 
12,000 feet, although definite changes were 
found at 18,000 feet. The Wickes' psychomotor 
apparatus required too long a training period 
to make its use practical in routine testing. The 
flicker fusion apparatus was found to be valu- 
able for experimental purposes but required too 



(uch training to make it practical for mass 
Tsting. direct comparison of flicker fusion 
and dotting tests under comparative condi- 
tions of anoxia, neither method gave a true 
evaluation of an individual's response to 

The Naval Air Station, Seattle, developed a 
,.^•(1 sorting test for use in the low-pressure 
chamber, to demonstrate the effects of anoxia. 
In this test, 89 percent of 200 individuals 
scored better at altitudes of 30,000 feet with 
oxygen than at 18,000 without oxygen. The 
test was unsuitable for use, however, because 
learning greatly influenced the test results, be- 
cause the results under anoxia were influenced 
by compensating factors, and because the test 
was relatively difficult to perform. 

In September 1945 the Naval Air Station, 
Vero Beach, Fla., developed a new ("M-N'') 
device for demonstrating effects of anoxia on 
night and day vision. This apparatus consisted 
of monocular and binocular "scopes" con- 
structed to allow the observer to view slides of 
aircraft silhouettes under ilkiminations ap- 
proximating that of starlight and average day- 
ght With this test 90 to 96 percent of sub- 
jects tested in a low-pressure chamber were 
convinced subjectively and objectively that 
anoxia impaired night vision. Ninety-eight 
percent of those tested were also convinced 
objectively of the anoxic effect on macular 

The Altitude Training Unit, Naval Air Sta- 
tion, Miami, reported on the measurement and 
demonstration of loss of visual function asso- 
ciated with anoxia and concluded that : (a) loss 
in range for targets observed under conditions 
of low illumination was evident at 5,000 feet ; 
(b) the loss in range above 10,000 feet when 
supplementary oxygen was not used was very 
great ; (c) the effect of anoxia on vision at alti- 
tudes below 10,000 feet was small and not 
considered of operational significance. Supple- 
mentary oxygen was therefore considered un- 
necessary below 12,000 feet. 

The Naval Air Station, Alameda, Calif, 
found that at altitudes of from 10,000 to 12,000 
feet differences in form perception at low 
levels of illumination using the Radium Plaque 
Adaptometer, were not measurable and that 

form perception of the completely dark adapted 
eye was not affected by the reduced barometric 
pressure at an altitude of 10,000 feet. 


Early in the war, the most pressing prob- 
lems were those of oxygen supply. The pro- 
curement of some type of oxygen equipment 
suitable for use during long flights in Cata- 
lina patrol planes was extremely urgent and 
the question of oxygen economy was para- 
mount. Partly for these reasons, a rebreather 
type system, using an oxygen regenerating 
chemical for both CO2 absorption and supple- 
mentary oxygen production, was adopted. The 
Medical Research Section and the Division of 
Aviation Medicine concluded that, in spite of 
its greater comfort, the lack of a demand fea- 
ture in the FWB recirculator obviated its gen- 
eral adoption. 

Many Navy fighter planes were equipped 
with a demand-type apparatus which, while 
having certain features superior to the re- 
breather, required large supplies of oxygen. 
Under the sponsorship of the Army Air 
Forces, various manufacturers were modify- 
ing the demand apparatus by incorporating a 
diluter valve which would admit measured 
quantities of ambient air at altitudes below 
30,000 feet. This type of apparatus offered 
many advantages over the rebreather type but 
still required considerably more compressed 
oxygen than the latter. 


The development of resuscitators was 
greatly stimulated by the problem of toxic 
gases resulting from shipboard fires. Aviation 
medical activities cooperated with BuShips and 
other agencies in attempts to provide adequate 
personnel protection against smoke from ship- 
board fires. Instances such as the holocaust 
aboard the carrier, U. S. S. Franklin, greatly 
stimulated the interest. As a result, in the sum- 
mer of 1945, for the first time, a resuscitator 
for general issue was added to the supply 


A large number of oxygen masks, including 
the MRS-1 mask developed by the Aviation 



Branch, Research Division, were tested. In 
general, the earlier efforts aimed toward de- 
vising masks that would fit perfectly, not 
freeze up at temperatures around -65"^ F., be 
comfortable to wear for long periods, and be 
durable under service conditions. During the 
course of the testing program, it became ob- 
vious that some compromise with these factors 
was necessary. The Type A-14 mask, developed 
by the Mayo Clinic and the Army Air Forces, 
was finally adopted as standard for use with 
the diluter demand regulator. 


Suitable methods for determining oxygen 
mask leakage were devised. In the early phases, 
tests such as presenting volatile substances in 
the vicinity of the mask were tried, but the 
results of these were unsatisfactory. Quantita- 
tive test methods included the so-called **spot" 
tests, which were either gasometric or volu- 
metric, and analysis of expired air collected 
over a period of several minutes. The Bureau 
of Aeronautics recommended the simple 
"spot'' test using devices such as the McKes- 
son Si)irometer for quick determinations of 
the adequacy of fit of an airman's mask. This 
was supplemented by the analysis of expired 
air when evaluating the fit of experimental 

It was found that all of the mechanical 
testers gave a large number of false failures, 
chiefly because the subject found it difficult to 
hold his breath for the required 10 seconds, 
but also because movement of the subject's 
head or jaw frequently- destroyed the pressure 
relationship between the mask and the tester 
regardless of the fit of the mask to the face. 

The Royal Canadian Air Force oxygen mask 
leak tester was evaluated in September 1945 
at Pensacola. It was concluded that its greater 
complexity of design, operation, and mainte^ 
nance, as compared to collapsible testers (as 
advocated by the Bureau of Aeronautics) made 
it undesirable for Navy use. 


On the basis of convenience and economy 

of weight, it was considered desirable to have 
oxygen for breathing purposes in airplanes in 

the form of a stable chemical compound whic)^ 
could be made to liberate gaseous oxygen wh^^^ 
desired. Chemicals as a source of oxygen foj. 
use in aviation were first utilized in the Navy 
rebreather. A substance known as *'GOX," ^ 
mixture of alkaline peroxides, mainly sodiuuj 
peroxide, served both to absorb CO2 and to p^^^^ 
duce from one-third to one-half of the total 
oxygen supplied during a run. 

For a number of years, the Naval Research 
Laboratory engaged in experimental work on 
the development of peroxides of metals other 
than sodium, and in cooperation with the Du 
Pont Comi)any developed a material known 
as '*KOK/' which consisted chiefly of potas- 
sium tetroxide. **KOK" supplied a much larger 
amount of oxygen than the earlier chemicals, 
so that a suitable canister filled with this ma- 
terial produced oxygen in excess of the user's 
demand and the excess could be employed to 
flush nitrogen from the rebreather system. 

In the early part of the war, the British 
utilized an "oxygen candle" for supplying 
ox\ g-en in small submarines. This device was 
adapted to aviation use through the coopera- 
tive efforts of the Naval Research Laboratory, 
the University of Pennsylvania, the National 
Defense Research Committee, and the Mine 
Safety Appliances Company under contract 
with the Bureau of Aeronautics. In one form, 
it was incorporated in an apparatus with a con- 
tinuous flow of approximately 20 minutes" 
duration; in another form, it \Nas cr)mi)ined 
with the '*KOK" described pi'eviously, in a 
2-hour rebreather apparatus designated the 
"C-K" unit. Neither unit was available in time 
for operational use during the war. 

Liquid oxygen 

On a volume basis, liquid oxygen was the 
most economical form in which to transport 
large quantities of oxygen for use in breath- 
ing equipment. During the war numerous 
methods to adapt this source to use in aircraft 
were tried. Two types of apparatus were most 
commonly used. One employed electrical en- 
ergy to convert the liquid to a gas; the other 
device utilized the environmental temperature 
to efl:ect the transformation. Physiological 
problems were concerned chiefly with the es- 



tablishxttent of peak rates of flow required 
from a converter designed for multi-place air- 
craft, and the possible inhalation of oxygen 
at very low temperatures. Owing to a number 
of engineering diliiculties, liquid oxygen was 
never installed in naval aircraft. 

In November 1945 the Naval Medical Re- 
search Institute evaluated the chlorate candles 
devised by the Naval Research Laboratory as 

source of oxygen supply for aircraft use. 
These candles gave oxygen percentages of 
from 95.6 to 97.2 percent, plus insignificant 
amounts of CO and COo. The initial smoke, 
however, was frequently unpleasant and was 
sometimes irritating enough to necessitate 
removal of the mask. 


In November 1945 the Altitude Training 

Unit at the Naval Air Station, Norfolk, on 
checking aviation personnel to determine their 
knowledge of oxygen equipment, found that 
the ability to use this equipment deteriorates 
very rapidly, especially w^hen instructions w^ere 
not given periodically. Lectures, low-pressure 
chamber '"flights," and actual aircraft flights 
were all valuable in contributing to knowledge 
of the use of oxygen equipment, but experience 
with the actual equipment in aircraft was the 
most important. 

A method was devised for the direct estima- 
tion of the gas tensions in blood samples which 
were obtained by the use of an indwelling 
arterial needle. It was noted that great varia- 
tions occurred in the arterial oxygen tension 
when exercise was done at high altitude. 

In February 1944 the microgasometric 
method of Roughton and Scholander for the 
determination of oxygen saturations of '*cap- 
illary" blood was adopted. The oxygen satura- 
tions of "capillary" blood obtained from the 
heated earlobe were compared with those of 
samples of arterial blood obtained simultane- 
ously from the brachial artery and found to 
correspond under a variety of conditions and 
levels of anoxemia. This method furnished a 
simple and accurate means of determining 
arterial oxygen saturations without recourse to 
arterial puncture. 

A study of the arterial oxyhemoglobin satu- 
rations in men breathing various oxygen-nitro- 
gen mixtures at critical pressure altitudes in 
the decompression chamber was made. In 43 
observations on 24 subjects at 20,000, 35,000, 
and 40,000 feet, the following facts were 
noted: (a) the oxyhemoglobin saturation may 
be predicted with an accuracy of plus or minus 
3 percent for a given oxygen-nitrogen mixture 
at these pressures; and (b) the arterial oxy- 
hemoglobin saturation may fall api:)reciably 
during a short period of medium to heavy work 
(in states of mild anoxia), during which time 
certain undetermined factors operate to make 
the saturation unpredictable. 

In January 1945 a direct method for the 
determination of oxygen and carbon dioxide 
tensions in blood was reported. This method 
involved the equilibration of a bubble of gas 
with blood at 37' C, and the analysis of this 
bubble for CO. and 0.. The Roughton-Scho- 
lander syringe was used both as an equilibra- 
tion chamber and a bubble analyzer, thus elimi- 
nating any transfer of the bubble. The results 
of this technique agreed very closely with those 
obtained using a tonometer at sea level, for 
both COj and 0:... Comparing the results at 
altitude in the low-pressure chamber, the 
method was also found accurate enough for 
practical purposes, and this technique was suf- 
ficiently simple, quick, and accurate for appli- 
cation to problems in respiratory physiology. 

In July 1944 the individual variation in 
respiratory responses to CO- at altitude were 
studied and it was concluded that the response 
of a group of subjects to C0 > was the same at 
15,000 feet pressure altitude as at sea level, 
when the same tension of COo in the inspired 
air was used. 

The altitude training unit at the Naval Sta- 
tion, Miami, studied the effect of temperature 
on anoxic failure in altitude chambers and 
noted that the average incidence for failure at 
18,000 feet approximated 3 peix-ent in ordinary 
low-pressure chamber runs, whereas only 0.3 
percent of men given chilled runs showed 
anoxic failure at this altitude. The accumula- 
tion of oxygen was no different in the warm 
or cold runs. The findings suggested that im- 
proved vascular tone due to cold and shiver- 



ing increases resistance to vasomotor collapse, 
despite the increase in oxygen consumption. 

The Naval Medical Research Institute 
studied the urea clearance of men at simu- 
lated altitudes of 18,000 feet for 1 hour (in 
a low-pressure chamber) and found no signifi- 
cant variations. In February 1943, v^ith the 
use of the ''pneumolotar" of the General Elec- 
tric X-ray Corporation, subjects were able to 
undergo flights to 45,000 and 50,000 feet in 
low-pressure chamber without any other equip- 
ment. Intermittent pressure breathing of air 
enabled men to remain at 22,000 feet for 30 
minutes without distress and at 25,000 feet for 
15 minutes with some distress, when the pres- 
sure was of the order of 8 inches HoO. This 
increase in "ceiling" of about 6,000 feet indi- 
cated greatly increased safety of oxygen ad- 
ministration for the aviator. 

The Altitude Training Unit at Pensacola 
conducted studies on the rate of fall of blood 

oxygen saturation at high altitudes following 
mask removals. At altitudes of 28,000 feet and 
above, a subject*s mask was removed and he 
performed a simple card-sorting task while 
his reactions were noted and recorded. When 
unconsciousness was imminent, the mask was 
replaced and 100 percent oxygen administered. 
Blood oxygen saturations were estimated 
throughout the procedures with a Millikan 
oximeter, and ambient oxygen pressure was 
determined with a continuous oxygen analyzer. 

Blood oxygen saturations averaged 64 per- 
cent at the appearance of the first error and 
56 percent at the time unconsciousness became 
imminent. This procedure was repeated on 25 
men at 28,000, 30,000, 35,000, and 38,000 feet. It 
w^as found that unconsciousness was imminent 
after 141 seconds at 28,000 feet, 98 seconds at 
30,000 feet, 72 seconds at 35,000 feet, and 47 
seconds at 38,000 feet, w^hile average time of 
useful consciousness as determined by the ap- 
pearance of the first error in card sorting was 
110 seconds at 28,000 feet, 73 seconds at 30,000 
feet, 46 seconds at 35,000 feet, and 35 seconds 
at 38,000 feet. Thus, the period of useful 
consciousness was found to be approximately 
three-fourths of the total period of conscious- 

In August 1945 workers reported the effopt 
on the blood cells in man of acute hypo^j^ 
with and without added CO2. They found that 
exposure of 29 men to low^ered oxygen tension 
(10 percent oxygen in nitrogen) for 20 minute, 
produced no immediate significant alteratio^ 
in the white blood cell count, red blood ce]] 
count, hematocrit, hemoglobin concentration 
or red blood cell volume. Addition of carbon 
dioxide (2 to 5 percent) did not alter lies^ 

The Naval Medical Research Institute studieii 
the transfusion of human erythrocytes as 
means of increasing tolerance to hypoxia, a 
total of 1,300 ml. of 55 percent fresh erythro- 
cyte suspension in saline was administered 
intravenously to each of two subjects over a 
period of 3 days. The transfusions were well 
tolerated, causing only mild symptoms. The 
hematocrit reading was increased from 45.8 
percent to 52.7 percent in one subject and from 
50.0 percent to 56.1 percent in the other sub- 
ject — an increase of approximately 12 percent 
in the total cell volume. The increased hema- 
tocrit readings returned to normal over a 
period of about 1 month. After 12 days, the 
increase was still greater than half the peak 
value attained. Analysis of arterial blood 
samples taken at altitudes indicated that the 
percentage saturation of hemoglobin with 
oxygen was within the normal range for the 
ambient oxygen partial pressure. Thus, the 
oxygen content of the blood, as well as the 
oxygen capacity, was greater than normal 
at this altitude. In tests made at simulated 
altitude of 18,000 feet to determine any devia- 
tion from normal reaction, the subjects who 
had had previous experience in low-pressure 
work noted an improved tolerance to hypoxia 
during the several days of polycythemia. 

The Altitude Training Unit at the Naval 
Air Station, Norfolk, tested aviation personnel 
to obtain their reaction to inspiratory obstruc- 
tion at simulated high altitudes. Exposing 50 
naval aviators, without warning, to inspiratory 
obstruction resulting from an induced failure 
of the oxygen supply at 30,000 feet simulated 
altitude, they found that all of the subject^ 
within 17 seconds, plus or minus 2 seconds, 
were certain of the time when the obstruction 



took place. This response was considered tan- 
tamount to an immediate warning of oxygen 
failure. All subjects showed anxiety at the 
udden increased resistance to breathing. 
Trained subjects w^ere able to handle the 
situation adequately while untrained subjects 
showed signs of varying degrees of mental 
confusion. On the basis of this study, the 
Ajorfolk group suggested that an oxygen regu- 
lator equipped with an automatic device to 
warn aviators of the loss of oxygen should be 

Development of pressure breathing 

Pressure-breathing oxygen regulator and 
bail-out equipment were developed by Gressly. 
A limited numl)er of these devices w^ere in 
use for high altitude flight. One phase of pres- 
sure breathing almost exclusively a Navy inno- 
vation was the development of an emergency 
breathing procedure (EBP). This 'Voluntary 
pressure breathing" was designed as an emer- 
gency maneuver for use in the event of failure 
of the oxygen supply. At altitudes up to 25,000 
feet, it was considered advantageous to exert 
pressure by contracting the respiratory muscles 
while holding a deep breath. 

In October 1943 it was found that EBP of 
air increased an aviator's ceiling by approxi- 
mately 10,000 feet and thus enabled an aviator, 
without equipment of any kind, to remain alert 
and conscious at altitudes of 25,000 to 26,000 
feet for periods of as long as 30 minutes. This 
procedure could successfully be taught to 
aviators by means of a supervised training run 
in a low-pressure chamber. It appeared to have 
usefulness in sustaining aviators at high alti- 
tudes in emergeneies, during parachute falls 
from high altitudes, and as an emergency pro- 
cedure in aircraft pressurized cabins. 

In actual flight tests at simulated altitudes 
of 25,000 feet for 10, 18, 21, 24, and 26 
minutes, copilots were able to maintain the 
aircraft on instruments, and the radioman 
functioned successfully — all without oxygen. 
One man was able to recover from anoxia after 
its onset. Hyperventilation, on the contrary, 
was not considered to be an adequate means 6f 

survival without oxygen at 25,000 feet because 
an arterial oxygen saturation of only 65 to 
70 percent was achieved and most subjects 
collapsed from anoxia, acapnia, or both within 
8 minutes. Using EBP of 100 percent oxygen, 
an altitude of 40,000 feet could be reached 
with ordinary oxygen equipment, and the phys- 
iological ceiling could possibly be raised to 
approximately 50,000 feet. 

Several dangers inherent in the use of EBP 
included: (a) The development in some in- 
stances of severe degrees of acapnia (even 
tetany) due to hyperventilation ; (6) the inade- 
quate respiratory coordination in some men, 
wdth resultant impairment of "altitude toler- 
ance;" (c) the diflSculties involved in indoc- 
trinating large groups of men in performing 
the technique efficiently; and (d) the possible 
development of overconfidence in an emergency 
maneuver which might encourage attempts to 
fly at hazardous altitudes without oxygen. The 
Naval Medical Research Institute found in tests 
at 25,000 feet that no advantage was gained 
by * 'pressure breathing'' during hyperventila- 
tion and that EBP and voluntary hyperventila- 
tion were equally effective in increasing the 
oxygen saturation of arterial blood when 
breathing ambient air at simulated altitudes 
of from 18,000 to 20,000 feet. They concluded 
that EBP was impractical for aviation person- 
nel, hyperventilation at the rate of 12 to 15 
breaths per minute being easier and less fati- 
guing than EBP at the same rate, and equally 


At Camp Lejeune the effects of scopolamine 
on marksmanship were studied and it was 
found that men given this drug performed with 
equal efficiency before and after its administra- 
tion. In February 1943 the effects of benzedrine 
on '*fire power" (hits per minute) under condi- 
tions of extreme fatigue were observed. It was 
found that 10 mg. doses at 8-hour intervals 
significantly increased fire power of personnel 
subjected to arduous tasks, although a slight 
degree of euphoria and diminished judgment 
was evident. 



Safety Devices and Survival 


Naval aviation medical personnel played an 
active part in the development of airborne 
equipment to aid in the handling of survivors. 
Improved litters, hoists, droppable rafts, first- 
aid kits, and methods of packaging medical 
supplies for dropping to survivors were per- 
fected by the cooperative efforts of engineer- 
ing and medical personnel. In 1944 the Air- 
Sea Rescue Agency designated a committee 
to study the medical and physiological aspects 
of air-sea rescue, and representatives of the 
Army, Navy, Coast Guard, and Public Health 
Service met at frequent intervals to coordinate 
their efforts in this study. 

Subjects investigated at naval aviation activ- 
ities included sunburn protective ointments, 
life preservers (with regard to the optimal 
flotation position in the event of unconscious- 
ness), prevention and alleviation of immersion 
foot, shark repellents, optimal position to be 
taken by personnel during ditching, protection 
against undemvater blast, testing of various 
signaling devices, and the use of oxygen equip- 
ment for emergency escape from submerged 
or sinking aircraft. In May 1944 the Naval 
Medical Research Institute designed an indi- 
vidual personal first-aid kit for aviation per- 
sonnel. This was a compact shock and moisture 
resistant plastic container holding a sufficient 
quantity of essential first-aid materials for one 
man until he could obtain help. Shelesnyak, in 
April 1945, devised a compact first-aid kit for 
use in aeronautic pneumatic liferafts. 


The problems of toxic gas centered around 
the entrance of exhaust gases into the cockpits 
of naval aircraft. Certain structural character- 
istics of carrier-based aircraft made this 
problem more serious in naval planes than in 
Army type planes. In the early part of the war, 
very little was known about the effects of 
carbon monoxide on the body when exposure 
occurred at altitudes involving moderate 
degrees of anoxia. There was a tendency toward 
ultraconservatism, and the limits of CO con- 

centration set by some branches of the service 
were almost infinitesimal. For these reasons 
two main lines of development were empha' 
sized: (a) study of the effects of carbon mon. 
oxide during periods of altitude anoxia and 
(&) the development of instruments for nieag. 
uring CO concentrations in air and blood, 
these studies, it was necessary to determine 
whether or not there were any other substances 
in the exhaust from airplane engines which 
would add to the toxicity of the carbon mon- 
oxide. It was concluded that while certain 
aldehydes might be a source of irritation the 
toxicity of exhaust gases could be suitably 
evaluated on the basis of their carbon monoxide 
content alone. The policy of determining blood 
level, rather than the air concentration of CO 
was adopted as a standard by the Bureau of 
Aeronautics. Using the changes in the critical 
frequency of flicker, it was established that 8 
to 10 percent carbon monoxide hemoglobin 
depressed altitude tolerance by 4,000 to 6,000 
feet at altitudes around 10,000 feet. 

In August 1945 a study of the in vivo 
equilibrium between oxy-, carboxy-, and re- 
duced hemoglobin in the blood of human sub- 
jects breathing gas mixtures containing from 
0.006 to 0.015 percent carbon monoxide indi- 
cated that the amount of COH,. could be deter- 
mined from the Haldane equation, knowing 
only the percentage of CO in the inspired air 
and the air pressure. Furthermore the symp- 
toms produced by CO were proportional not 
only to the blood concentration of COHb but 
also to the duration of exposure to given con- 
centrations of CO. 

The MSA portable Hopcalite carbon mon- 
oxide indicator was compared with the bulb 
type colorimeter. The colorimeter had a pos- 
sible eri^or as great as 0.007 percent, especially 
when estimating small concentrations of carbon 
monoxide (below 0.005 percent). 

Investigation of the toxic gases resulting 
from jet-assisted take-offs (JATO) showed that 
hydrochloric acid and carbon monoxide consti- 
tute the worst hazards to personnel exposed 
to JATO on carrier flight decks. 





In September 1942 the National Institute 
f Health demonstrated the superiority of red 
ivhting over fluorescent Ughting for reading 
aeronautical charts and for preserving dark 

As a result of a questionnaire submitted to 
400 pilots, it was determined that the greatest 
aifficulties in night flying were confusion of 
lights, inability to judge speed and distance, 
and disorientation or vertigo. It was found that 
the accident rate greatly increased as the 
evening advanced. This was shown to be pri- 
marily due not to increasing darkness but to 
sleepiness and fatigue which significantly 
increased in the later night hours. Taxiing 
accidents occurred equally under moon and 
moonless conditions, but landing accidents 
attributed to leveling olT too high occurred 
more frequently in moonlight. 

Ultraviolet and indirect red systems of 
illumination for aircraft instrument panels 
were compared. When the brightness level was 
greater than that required for minimum legi- 
bility, ultraviolet illumination caused a sharp 
decrease in the efficiency of spotting faint tar- 
gets against the sky background, while red had 
very little effect. 

Early in the war the source of supply for the 
Ishihara color plates was cut off from the Navy 
and a new color test became imperative. The 
effect of tinted lenses on color vision w\is 
checked and it was found that neutral and 
greenish lenses produced little effect on color 
perception. Reddish-orange lenses caused an 
effect equivalent to that of moderate color 
blindness and yellow lenses produced the effect 
of extreme color blindness. The aftereffects 
of wearing any colored lenses diminished 


Reduction in size of permetric field was 
observed in subjects exposed to prolonged 
physiologic stress, other than anoxia, but this 
^as probably no greater than that observed 
under nonstress conditions* 

Test firing under low illumination showed 
that practical advantage is to be gained 
through the wearing of dark adapter goggles. 


The dark adaptation threshold of officers as 

compared with enlisted men was studied on 
the U.S.S. Enterprise, using the Hecht-Schlaer 
adaptometer, and no significant difference was 
found. All subjects who were deficient in orig- 
inal testing, improved on vitamin A administra- 

The optimal lighting level in ready rooms 
for cone function of personnel wearing dark 
adaptation goggles was found to be between 
20 and 30 foot-candles. At this level, the optimal 
time for dark adaptation, wearing the red 
goggles, was 45 minutes followed by 2 minutes 
of complete darkness. After exposure to light 
levels above 30 foot-candles, an excessive 
amount of time was required to fully dark- 
adapt, while levels below 20 foot-candles gave 
insuflBcient illumination for cone function. If 
all-red lighting was used instead of the goggles, 
the intensity required was between 2.5 and 3.8 
foot-candles. It was concluded that any night 
vision training device should be binocular 
rather than monocular, because at low illumi- 
nations the perceptual threshold was lower for 
binocular than for monocular viewing. 

A study of dark adaptation while wearing 
orange dark adapter goggles indicated that 
standard red goggles were superior to 5 percent 
orange goggles and to 5 and 10 percent neutral 
goggles under conditions demanding quick 
recovery of complete dark adaptation. Where 
somewhat less complete recovery was required, 
the 5 percent orange goggles were almost as 
efficient as the standard red ones. 

Sunlight produced temporary and cumulative 
effects on night vision. A single exposure of 
2 to 3 hours delayed the onset of dark adapta- 
tion by 10 minutes or more, and night vision 
threshold was not reached for several hours. 
With repeated daily exposure to sunlight, the 
delay in reaching the normal threshold per- 
sisted overnight. This threshold, after com- 

238015—53 17 



plete dark adaptation, was higher each day for 
about 10 days and then remained at the high- 
est level. This elevated threshold corresponded 
to an average deterioration of about 50 percent 
in visual acuity, range of visibility, contrast 
discrimination, and in the frequency of picking 
up a barely visible target. This chronic effect 
did not disappear even after 10 days of pro- 
tection from sunlight and was approximately 
equivalent to the loss in night vision experi- 
enced at altitudes of 12,000 feet without oxygen. 
These workers concluded that adequate sun- 
glasses should be worn by all persons exposed 
to bright sunlight during the day, if they expect 
to perform critical night duties. 


1. Development and testing of Anti-G pro- 
tection devices. 

2. Study of physiological effects of rapid 
ascent to high altitudes for establishment of 
criteria for advanced type aircraft. 

3. Development of new micro techniques for 
visualization of air embolism in living tissues. 

4. Development of preoxygenation tech- 
niques for prevention of divers' bends and air 
embolism in aviators. 

5. Establishment of human breathing pat- 
terns at sea level and altitude for use in design 
of aviators' oxygen breathing equipment. 

6. Flight testing and evaluation of Navy 
aircraft oxygen regulators. 

7. Establishment of criteria for design of 
Bureau of Aeronautics oxygen equipment. 

8. Development of a simple flowmeter type 
apparatus for testing oxygen regulators in 

9. Establishment of standards for size dis- 
tribution of A-14 oxygen mask for use by 
naval personnel. 

10. Comparative tests of devices for testing 
of high altitude oxygen mask leakage leading 
to modification of existing equipment. 

11. Development of procedure for instruction 
and indoctrination of key aviators in problems 
of high altitude flight and pressure oxygen 
breathing equipment. 


12. Evaluation of techniques employe^i • 
oxygen indoctrination of aviation personnel 

13. Development and evaluation of vol^^^ 
tary pressure breathing methods and tech 

14. Development of new simple methods for 

blood gas analysis. 

15. Investigation and recommendations, 
garding dental pain occurring in flight. 

16. Evaluation of visual standards forj 
in selection of naval aviators. 

17. Development of aptitude tests for selec. 
tion of naval aviators, flight instructors, 
aircraft gunners. 

18. Development of improved techniques in 
aircraft intercommunication systems and in 
speech intelligibility of communication in air- 

19. Development for liferafts of an emer- 
genc\^ ration and of headgear protective against 

the sun. 

20. Evaluation of motion sickness preven- 
tives for use in liferaft first-aid kits, leading 
to recommendations for adoption of scopola- 

21. Development of individual first-aid kit 
for flying personnel. 

22. Development of techniques for dropping 
of medical supplies from aircraft. 

23. Development of improved naval in-flight 

24. Development of special methods for 
interior and exterior lighting of aircraft. 

25. Establishment of method of illuminating 

submarine conning towers. 

26. Determination of and recommendation of 
methods for elimination of factors causing dis- 
orientation in pilots during flight at night. 

27. Establishment of criteria based on human 
factors for the design, placement, and operation 
of instruments and controls in aircraft, and for 
pilot comfort, efficiency, and escape. 

28. Development of nylon aviator's flak suit. 

29. Evaluation of crash injuries, leading to 
establishment of methods for prevention. 

30. Development of harness for protection 
against crash deceleration and parachute open- 
ing shock. 



3l Testing of and recommendations for im- 

•ovenient of ventilation on naval aircraft and 
JJrcraft carriers. 

32. Recominendations based on the investi- 
ntion of toxic gases produced by JATO units. 

03 Development of single aperture goggle 
for uninteri'upted, v^ide-angle vision. 

34. Development of red goggles for dark 

35. Development of radium plaque adapto- 
j^^eter for night vision testing. 

36. Development of brow-rest all-purpose 
Navy sunglasses. 

37. Development of sun-scanning visor for 
ground, ship, and flying personnel. 

38. Research leading to the establishment of 
specifications for aviator's neutral sunglasses. 

39. Development of equipment for indoctri- 

nation of naval personnel in techniques to aid 
in night vision. 

40. Recommendation for methods of preven- 
tion of deleterious effects of exposure to intense 
sunlight on subsequent night vision. 

41. Development of antifluorescent goggle 
to prevent dazzling of landing signal officer. 

42. Development of new color vision test 

43. Development of new Navy color vision 
testing lantern. 

44. Development of a field method for the 
measurement of the central scotoma under dim 

45. Development and evaluation of test 
targets for measuring visual acuity. 

46. Evaluation of the Orthorater, Sight- 
Screener, and Telebinocular as compared to 
standard methods of visual testing. 

Chapter XI 


Lament Pugh, Rear Admiral (MC) USN 

The stimulus for medical and surgical ad- 
vancement occasioned by World War II was 
very great. This was particularly applicable 
to the management of burns. In the Navy and 
Marine Corps the case fatality rate for burns 
was only 8.7 percent as compared with 22.9 
percent in World War I. The difference of 14.2 
percent was indicative of improvement in the 
methods of burn management. Perhaps not all 
of this improvement was attributable to meas- 
ures or principles born of the war's stimulus; 
to some extent it was ascribable to progress 
made during the interval between World War 
I and World War II. Of significance, however, 
was the fatality rate for burns of 17.4 percent 
in 1942 which dropped to about 6 percent in 
1944 and 1945, definitely indicating improve- 
ment in treatment ascribable to the war's 
stimulus. Figures provided by the Army 
closely paralleled those of the Navy. 

Whatever change the concept of burn man- 
agement may have undergone during World 
War II, that change was wrought, in an 
appreciable measure, by what was unlearned 
rather than by what was learned. We were 
still short of an ideal regimen in the treatment 
of burns and there remained differences of 
opinion among various groups as to what 
constituted the best regimen, save that prac- 
tically all were in agreement that simplicity 
was a prime requisite. Certain principles 
became fairly well standardized. These re- 
solved themselves into three categories, namely, 
general and local treatment and rehabilitation. 


1. A more intelligent appraisal of the value 
of blood plasma and a more general realization 
of its limitations were developed. While the 
sheet anchor in the management of shock was 

blood plasma, it alone was not sufficient in 
severely shocked patients. Certain other ele- 
ments were essential as a complement to plasma 
in order that the most effective means to com- 
bat or treat shock could be provided and condi- 
tions most favorable to healing maintained. 
Supplementary use of an extract of whole 
adrenal cortex made it possible to successfully 
cope with shock in stages beyond the reach 
of plasma alone. At least that was my convic- ' 
tion. Concentrated albumin had its indications 
and advantages in the management of burn 
shock. Based upon sound reasoning, the use 
of an amino acid solution or casein hydrolyzate 
as a means of maintaining the blood protein 
balance gained favor and stood to supplant 
plasma completely. Buffers to maintain a proper 
acid-base balance were also taken into account. 

2. The importance of maintaining a positive 
nitrogen balance by either oral or parenteral 
administration of protein was generally recog- 
nized. A high protein diet and an adequate vita- 
min intake, particularly of thiamine and ascor- 
bic acid, was deemed essential. 

3. The essentiality of whole blood transfu- 
sions in certain patients received general recog- 
nition. In severely burned patients, cachexia 
often supervened despite the most caref ul tr^at- - 
ment, and death, sometimes months after the 
original burn and regardless of what was done, 
was the rule. Repeated whole blood transfusions 
were necessary — nothing sufficed in their stead 
and nothing contributed more to the patient's 
chances of living. 

4. A better understanding was developed of 
the proneness of certain complications such as 
pneumonia to supervene. 

5. A more intelligent appraisal of or realiza- 
tion of the merits and demerits of the sulfa 



drugs, penicillin, and other antibiotics canae 
to exist. 


The most notable advancements in local 
treatment of burns included: 

1. The virtual abandonment of tannic acid 
and other coagulants, including silver nitrate, 
the dyes, picric acid, and the proprietary for- 

2. A return to the old emollients such as 
vaseline, vaseline and paratRn (parawax), and 
boric acid ointment, 

3. A fuller appreciation of the importance 
of protection of the burned area from infection, 
and the prevention of further damage that 
resulted when burned surfaces were in apposi- 

4. The popularization of the pressure dress- 
ing. The rationale of the pressure dressing 
was based upon three important principles: 
(a) The prevention of circulatory stagnation 
and of fluid loss, along with the support of the 
part; (b) the reduction of the risk of intro- 
ducing secondary infection by leaving the part 
alone; and (c) the elimination of the painful 
ordeal of repeated changing of the dressings, 
which was gratifying to the patient. 

5. The pronounced trend toward early skin 
grafting and the popularization of the patch 
graft. Skin graftin^^ was generally done within 
about 3 weeks. Early skin grafting was insti- 
tuted more and more freely, not primarily as a 
plastic procedure but as a conservation measure 
to preserve the deeper structures, prevent fur- 
ther fluid loss, prevent infection, and conserve 

the general health of the patient. The ty™ 
graft used was governed largely by what tT 
particular surgeon had found would be 
likely to grow. Patch grafts were very poptfl^ 
This method involved removing a split thic^ 

ness sheet of skin and cutting it up into 


pieces. Infection was not nearly so likely 
prevent a take when the patch graft was used 


The importance, from both a sociologic and 
economic standpoint, of rehabilitation of 
burned patients was more and more fuHy 
realized, but too f i-equently was neglected. This 
phase of therapy often presented a challenge 
of the first magnitude, which in the well-ordered 
hospital was satisfactorily met, at least in 
cases of burns involving the hand, through 
the medium of a ''hand" board comprised of 
an orthopedic surgeon, plastic surgeon, and 
neurosurgeon. These specialists collaborated 
upon the matter of the salvage and restoration 
of function of burned hands, 


The development and provision of prophy- 
lactic measures in the form of special clothing 
and local applications to meet the needs of a 
rapidly changing world were born of and given 
impetus by the war. Efforts toward prevention 
of burns and improvement in their treatment 
were continued. Great advances were made in 
devising protective covering and local applied 
tions as prophylactic measures against burns, 
for military and naval as well as for industrial 

Chapter XII 

Program for the Deaf 

Ross T Mclnlire, Vice Admiral (MC) USN (Retired) 

The treatment of deafness has given the 
otologist great concern for decades. The causes 
of deafness have been reasonably v^ell under- 
stood, but a sound approach in prophylaxis 
had never been achieved and the results of 
research in this disability were disappointing. 

Three types of deafness have been recog- 
nized: (a) The chronic progressive type; (b) 
the nerve type; and (c) the type following 
chronic otitis media. In chronic, progressive 
deafness the predominant findings are: (1) 
Reasonably normal tympanic membranes; (2) 
a negative Rinne test; and (3) a gradually 
increasing profundity of hearing impairment. 
The patient often has a familial history of 
deafness, and audiometric tests show a mixed 
loss of hearing tones. 

The nerve type of deafness, as seen in the 
Navy, was often traceable to damage from 
heavy gunfire. It was reasonable to expect that 
damage to the acoustic mechanism might cause 
immediate deafness. This was not true. Due to 
the inflammation of the end organ an immedi- 
ate loss occurred, but usually there was some 
improvement in a few days. We observed that 
there was a slow loss of hearing over a period 
of from 1 to 2 years, until the deafness became 
severe enough to be incapacitating. 

One of the most common complaints of pa- 
tients suffering from nerve involvements was 
tinnitus associated with headache; some com- 
plained of vertigo. Unfortunately, the patient 
frequently failed to consult a medical officer 
until his hearing reached such a low level that 
the deafness was very difficult to treat. 

One of the conditions that was always con- 
sidered was malingering. In fact, the man who 
had nerve deafness was likely to give one the 
impression that he was malingering. Situa- 
tional deafness occurred in some men following 

gunfire, blast, or the noise of heavy machinery. 
This condition was supported by functional and 
audiometric tests, and usually the disabiltiy 
was of relatively short duration. Men who had 
this condition were often psychologically un- 
stable and were often classified as malingerers. 

One of the great troubles we experienced was 
to get the patient under treatment in a reason- 
ably short time; our average was 6 to 18 
months. In other words, the patient with nerve 
deafness went through the cycle of typical 
gunfire hearing loss before he was seen. This 
was something that civilian specialists should 
consider in those patients who have been sub- 
jected to blast and noise in industrial occu- 

We believed that the upper respiratory tract 
played a most important role in the causation 
of infections of the eustacian tube, middle ear, 
and mastoid process, and that nerve deafness 
often resulted from foci of infection. 

The fenestration operation developed by 
Lempert offered hope for the patient with true 
otosclerosis. After operation, over 65 percent 
of the patients showed recovery to normal 
hearing levels. Because of this fact, the Navy 
trained a number of its specialists in the tech- 
nique of this operation. 

Rehabilitation of the deaf was carried on in 
the Acoustic Clinic set up at the Naval Hospital, 
Philadelphia. The program was designed for 
the patient who had permanently lost some or 
all of his hearing. The discovery of this loss 
and its implications represented for him a 
major crisis in adjustment and he had to learn 
to live as successfully and happily as possible 
despite his loss. 

The first task in rehabilitation was to select, 
train, and supervise a staff of specialists, so 
that the psycho-physio-social problems of the 



deaf could be attacked intelligently. We found 
that the psychological upset that occurred in 
the deafened man was greater than that in the 
blinded man. The lack of proper hearing dis- 
turbs speech, and when a man misses a key 
word in a sentence because of his hearing de- 
fect his reply is based on an erroneous assump- 
tion. After a number of false answers his per- 
sonality suffers. 

To measure the actual hearing deficit by 
decibels was necessary, because many patients 
who sulfered only slight loss in hearing acuity 
were more seriously handicapped than those 
who had a very great defect. Such differences 
could only be explained in terms of the indi- 
vidual personality. It was considered impera- 
tive, therefore, that the rehabilitation processes 
be individualized. It was essential that a sincere 
effort be made to understand the man who had 
a hearing loss. The patient was prepared psy- 
chologically to accept the fact that his chances 
of improvement in hearing were too small to 
run the risk of waiting for it to occur, and to 
accept the practical course of developing effec- 
tive structures of compensation that would be 
as permanent as the disorder itself. 

A sudden loss of hearing often had a heavy 
impact upon the personality of the man. Those 
who had lost hearing over a period of years 
w^ere often unconscious of the steady down- 
grade and had already made adjustments. This 
type of patient was difficult to treat, for they 
became eccentric and antisocial. The most posi- 
tive deterrent to the growth of these attitudes 
was the development of practical skill in com- 
munication by the employment of other sensory 
channels and by the effective use of residual 
capacities. The patient was made to realize 
that it was necessary to compete in a highly 
competitive world, and that he could be equip- 
ped to meet the competition with new abilities 
and skills. He w^as made aware that he was not 
a deafened man who must find ways to ap- 
pear normal, but rather that he could become a 
successful deafened man, if the residual hearing 
he possessed was put to its maximum use. 

Our experience justified the principle of 
treating the whole personality and of consider- 
ing the limitation of hearing as a significant 
but not disproportionately important part of 

the man. The over-all principle which unified 
our various methods defined order and direction 
for the specialists who might otherwise have 
attacked the problems in different ways. 

The method of the treatment of deafness Avas 
predicted on functional testing procedures 
diagnosis and an accurate evaluation of tj^^ 
results of treatment. In addition to the usual 
history and physical examination, fork tests 
audiograms, whispered and conversational 
voice tests, and speech reception tests, both 
monaural and in a free field, were employe^. 
These aided greatly in the accurate measure, 
ment of residual function. An apparatus was 
developed under the auspices of the National 
Research Council for the Army and Navy Aural 
Rehabilitation Services. This consisted essen- 
tially of an electronic device to transmit high 
fidelity recorded or free speech at any level of 
intensity. It was calibrated in decibels of from 
1 to 100 and noise masking could also be added 
in measured amounts. It was anticipated that 
use of this instrument before and after the 
fenestration operation, or other methods of 
treatment, would greatly facilitate evaluation 
of results. 

A careful search for factors that were opera- 
tive in the existing deafness was first made. 

Thus otitis media, if present, was treated either 
by medical or surgical means. Personnel who 
showed evidence of high susceptibility to 
acoustic trauma were cautioned to avoid future 
exposure. The use of ear wardens by persons 
necessarily exposed to loud noises, either of 
the continuous type such as those caused by 
airplane engines, or the explosive type, did 
much to reduce the incidence of traumatic 
deafness. Many young men had symptoms of 
persistent or recurrent eustacian salpingitis 
with peritubal lymphoid hyperplasia. These 
patients were treated with radium, using two 
50-mg. nasal applicators. Aero-otitis media in 
flying and diving personnel was similarly 
treated. Associated infection such as sinusitis 
was also treated intensively. 

Patients that were suitable for the fenestra- 
tion operation, that is, those with noncatarrhal 
conductive deafness (otosclerosis) showing at 
least 40 decibels (db.) loss in the better ear 
for speech frequency, were offered the advan- 



ta^es of this operation. Because hearing aids 
^yere most effective in this type of deafness, 
many preferred wearing an aid to undergoing 
an operation. In a successful operation, the 
patient usually obtained a gain in hearing of 
from 25 to 30 db. Patients showing no middle 
gar disease or tympanic scarring, no appre- 
ciable loss of hearing for high frequencies, and 
a decibel loss no greater than 60 in the speech 
frequencies were considered to be suitable for 
operation. Even with good results from the 
operation, a hearing aid was necessary if the 
gain failed to raise the threshold to 30 db. 

The mental attitude of the patient was con- 
sidered to be most important in both diagnosis 
and treatment. Recently deafened persons 
minimize or hide their defect. They become sen- 
sitive or irritable or introspective and detached. 
Some patients developed psychogenic overlays, 
thus exaggerating an existing organic deaf- 
ness ; others manifested typical hysterical deaf- 
ness. While the latter was rare, the former was 
not uncommonly engendered by worry, anxiety, 
and insecurity. 

Patients with mild forms of overlay usually 
required no treatment and the condition disap- 
peared as the hearing improved ; patients with 
severe types were treated by narcosynthesis 
or hypnosis. 

The recognition of a psychogenic component 
in deafness was important not only from the 
standpoint of prognosis, but also in the evalua- 
tion of therapy. Since it was not unusual to 
ascribe curative value to a treatment that acted 
largely by power of suggestion, the power of 
suggestion was utilized in inducing acceptance 
of a hearing handicap and of the urge to persist 
in a retraining program until the handicap 
became minimal. This retraining program con- 
sisted essentially of speech (Up) reading, audi- 
tory training, speech correction, and vocational 
training. Speech reading stressed not only the 
observation of lip movements but also included 
training in the interpretation of all cues such 
as facial expressions and gestures. This train- 
ing was particularly valuable in the type of 
nerve deafness where consonants were poorly 
heard. Since the intelligibility of speech was 
largely dependent on consonants, speech read- 
ing restored communication to those who previ- 

ously had only heard unintelligible vowels. 
Patients with mild deafness obtained prac- 
tically normal reception by the use of a hearing 
aid alone ; for those, lip reading was cultivated 
against the time when the deafness would 
become worse. In case of marked deafness of 
the mixed or nerve type, hearing aids usually 
did not give sufficient amplification of the 
higher frequencies for complete intelligibility, 
and lip reading was used to supplement the 
hearing aid. In complete deafness, speech read- 
ing was the main substitute for the hearing 
loss. Some persons with marked hearing loss 
benefited from a hearing aid by obtaining audi- 
tory cues to augment their lip reading ability. 

It was found necessary to match the hearing 
aid to the audiogram on the theory of selective 
amplification. In nerve deafness a slightly better 
performance was often obtained by the use of 
an aid with a 6 db. per octave "tilt," but such 
factors as amplification, quality of tone, and 
body baffle required careful consideration. 
Carefully fitted, individually molded ear pieces 
were provided for all patients at the outset of 
the retraining program. 

Hearing aids did not substitute for atrophied 
nerves and the patient with nerve deafness had 
to go through an orderly and prolonged train- 
ing process in order to get the maximum benefit 
from his aid, as well as to learn the limitations 
he had to accept. Many patients with nerve 
deafness could be successfully fitted with aids 
because precision instruments of high fidelity 
were available. 

Auditory training in World War II was a 
relatively new concept. The failure of many 
individuals to adapt themselves to a hearing 
aid in the past was largely due to intolerance 
of amplified sound. The patient with conductive 
deafness presents no great problem, because as 
soon as sound penetrates the barrier, it is ap- 
preciated as a threshold sound. In nerve deaf- 
ness on the other hand, as soon as the sound 
becomes audible, it is perceived as a loud sound 
and so may cause acute distress. The greater 
the hearing loss, the louder the sound seems to 
be when it becomes audible, because the patient 
was accustomed to a pathologically quiet world. 

Part of auditory rehabilitation consisted in 



teaching men how best to wear and care for 
the aid, as well as in defining its limitations. It 
was found useful to instruct patients in the 
elementary anatomy, physiology, and pathology 
of hearing, with particular emphasis on the 
type of disability the patient had. With this 
knowledge, the element of mystery was removed 
and the patient regained confidence. 

One of the factors that required thought was 

the care of the residual hearing of the deafen 
man. This required a central diagnostic clin* 
where the patient could be checked from t[J^ 
to time. It is the hope that in the field of soc J 
rehabilitation the experience gained in 
handling of the many thousands of individu^ig 
who suffered hearing defects during Wofij 
War II will be put to use for the deafened men 
women, and children in civil life. 

Chapter XIII 


Clifford A. Swanson, Rear Admiral (MC) USN 
Roy A. Stewart, Ueufenant (MC) USNR 

The medical and surgical care given to the 
injured fighting man in World War II was 
superb. It was characterized by better care of 
eve injuries, not so much because of improved 
surgical techniques as because of chemotherapy. 
The use of sulfonamides and penicillin soon 
after injuries occurred undoubtedly decreased 
the incidence and severity of eye complications. 
Although eye injuries during World War II 
provided an interesting aspect of military medi- 
cine, they comprised only a small percentage of 
the total number of injuries. 

Eye surgery during the war differed from 
that in civilian life in that often a wound of 
the eye was virulently infected for some days 
before surgical interference was possible. In 
addition, the tissue injury was far more severe 
than that noted in industrial accidents. The 
general surgeon followed a plan of early and 
extensive debridement of gunshot wounds, but 
such a course was not possible in wounds of the 
eyelids where primary suture was indicated. 
Infection following primary suture was rare 
and when it did occur it could be controlled 
easily. A feature of plastic surgery of the eye- 
lids that varied from that in civil life was the 
frequent occurrence of extensive injuries of the 
orbital bony structures. 

Iritis, corneal ulcers, refractive errors, and 
similar conditions often caused more loss in 
military manpower than did gunshot wounds 
of the eye.2 In one naval base hospital during 

^Adapted from: Causes of Uniocular and Binocular Blindness in 
the U. S. Navy and U. S. Marine Corps in World War II. U. S. 
Nav. M. Bull. 46: 520-527, Apr. 1946. 

2 The eye injuries during the American Revolution of 1776 and 
the War of 1812 were predominantly burns of the eyelids and eyes 
from the powder flash of the flintlock muskets or from bits of 
flint. The Civil War was noted for the frequent occurrence of 

a 1-year period, 10 times as many patients were 
admitted because of errors in refraction and 
disease of the eye than because of eye injury. 
When men with hyperopia were subjected to 
battle conditions they frequently had eye symp- 
toms; apparently the intraocular muscles can 
overcome a moderate hyperopia under normal 
conditions but not under the stress of war. 

In war wounds, the eye injury frequently 
was of secondary importance. The attendant 
major wound had to be cared for first and 
treatment of the eye injury was postponed until 
shock or serious body injury was treated. In 
order that injuries to the eyes should not be 
overlooked, a close liaison between the ophthal- 
mologist and the general surgeon was essential. 

Bullets rarely entered the eye anteriorly. 
Orbital injuries from secondary bony missiles 
often caused more damage to the eyeball than 
did the bullet. The eyeball sometimes literally 
''exploded'' in the orbit. 

Shell-fragment wounds of the tissues around 
the eye were often attended with powder- 
incrusted areas of the face and eyelids and 
embedded grains of sand, gravel, mud, and 
metal. This gave the extra-ocular regions as 
well as the cornea and conjunctiva a tattooed 
appearance. Such wounds were irrigated with 
boric acid solution, the skin cleansed with soap 
and water, and each bit of embedded material 
was painstakingly removed. The administration 
of penicillin and sulfadiazine greatly decreased 
the incidence of secondary infection in these 

Bomb explosions produced such great air 
compression that retrobulbar hemorrhage with 

sympathetic ophthalmia. World War I was noted not only for 
severe eye injuries caused by gunfire but also for ocular injuries 
caused by poisonous gases. 



proptosis, blindness, and subsequent optic 
atrophy occurred. Iridodialysis and rupture of 
the choroid with secondary glaucoma were 
also prone to occur. 

Burns of the face were noted frequently, but 
as a rule these did not produce blindness be- 
cause the eyelids were principally involved. It 
was sometimes necessary to suture the eyelids 
together as an adjuvant to treatment. 

Benkwith wrote an excellent description of 
injuries and diseases of the eye in war. In 
some of his patients with eye injuries, he 
irrigated the anterior chamber with a freshly 
prepared solution of calcium penicillin, 10,000 
units per cc, and made subconjunctival injec- 
tions using 2 cc. of this solution. 

In the statistics that follow (table 30) we 
have defined blindness as a visual acuity of 
20/200 or less, not correctible by any type 
of lens, or a permanent visual field of 15 
degrees or less in its widest diameter. The 
records studied did not in every case include 
a definite statement as to visual acuity ; there- 
fore, these figures may understate the actual 
number of cases of blindness. 

Table 30. — Blindness, Navy and Marine Corps 
World War II 




Caused by injury 





Binocular blindness. _ 
Uniocular blindness. _ 










Percent distribution: 

Binocular blindness. . 
Uniocular blindness. _ 
All blindness 





There were approximately 10 cases of uni- 
ocular blindness to 1 of binocular blindness. 
More than half of the cases of blindness resulted 
from injuries incurred in combat. Some of the 
war wounds causing bilateral blindness were 
almost freakish. One Marine was blinded by a 
bullet which penetrated the left temple and 
destroyed both eyes and the bridge of the nose. 
Bullet wounds accounted for only about 15 
percent of combat-incurred blindness, whereas 

wounds from shell fragments caused nearly 
60 percent. 

Noncombat injuries were responsible f^^ 
over one-fourth of the total number of cases 
of blindness. In about 40 percent, blindness 
resulted from lacerated or punctured woun^ 
of the globe; in 20 percent, blindness wj^g 
caused by foreign bodies. 

Disease and poisoning accounted for one- 
sixth of the total number of cases of blind, 
ness, and these were more often binocular than 
uniocular. Seventeen percent of all cases of 
binocular blindness was due to methyl alcohol 
poisoning. Of uniocular blindness due to dis- 
ease, neoplasms caused 8 percent and vascu- 
lar diseases 4 percent, but in the majority of 
cases the cause was less precise. The distribu- 
tion by site of uniocular blindness due to dis- 
ease was as follows : 


Eyeball, generally 26 

Cornea 12 

Iris 6 

Lens 10 

Chorid and retina 33 

Optic nerve, tracts, and centers 13 

Enucleation was performed on slightly more 
than one-third of the patients with blindness 
due to medical causes, and on 21 patients with 
panophthalmitis. Neoplasms, principally malig- 
nant melanoma, were a frequent indication for 

Intraocular foreign bodies were of particu- 
lar importance. In 67 percent the intraocular 
foreign bodies were classified as magnetic and 
in 33 percent nonmagnetic. In 50 percent of 
patients with intraocular foreign bodies, enu- 
cleation was necessary. While identical methods 
of handling intraocular foreign bodies were not 
used at all naval medical facilities, the diag- 
nostic and therapeutic measures cited were 
generally applicable. 

Frequently the injury was so extensive that 
the eye could not be saved, even though the 
intraocular foreign body was removed. Be- 
cause the equipment necessary for the removal 
of an intraocular foreign body was large and 
cumbersome, evacuation to a base hospital was 
often necessary and therefore valuable time 
was lost. Many of these foreign bodies were 
removed successfully, however, with the aid of 



portable x-ray machine and a silver v^ire 
nitured around the limbus to act as a locator. 

The history of the type of eye injury was 
niost important. Any evidence of a perforat- 
ing injury to the eyeball or a bloody vitreous 
niade one suspect an intraocular foreign body. 
\ small conjunctival laceration with a subcon- 
junctival hemorrhage was often the point of 
entrance of an intraocular foreign body. A 
careful examination with the loupe, slit lamp, 
and ophthalmoscope was the first step. A slit- 
lamp ophthalmoscope offered a valuable aid 
when the vitreous was cloudy. The point of 
entrance of an intraocular foreign body offered 
no definite clue as to its location. 

Roentgenography offered the best diagnostic 
aid for the presence and localization of an 
intraocular foreign body. A film taken in one 
or two positions did not always rule out an 
intraocular foreign body and it was often 
necessary to resort to Vogt's skeleton-free or 
bone-free method for foreign bodies in the an- 
terior part of the eyeball. With the retrobulbar 
injection of 2 or 4 cc. of physiological saline 
solution or 1 percent procaine hydrochloride, 
an artificial proptosis was produced and this 
frequently aided in roentgenographic diag- 

For successful removal of an intraocular 
foreign body accurate localization was most 
important. For magnetic intraocular foreign 
bodies the Herman locator offered much help 
and because of its portability it was used when 
an x-ray machine was not available. 

The question of a double perforation of the 
eyeball was frequently answered by injecting 
air into Tenon's capsule to produce proptosis, 
thus creating an area with a density different 
from that of the tissues surrounding the eye- 
ball and increasing the diagnostic effectiveness 
of roentgenography. 

Localization of the intraocular foreign body 
could be accomplished by the modified Sweet 
method or by the Comberg contact lens. Thorpe 
devised a plastic contact lens with suture holes 
in it so that the lens could be sutured to the 
episcleral tissue. Stereoscopic roentgenograms 
^vere necessary. 

If the anterior segment of the eyeball was 
intact and the foreign body was in the vitreous, 

it was removed by posterior sclerotomy. It 
was obvious that removal by the anterior route 
would result in damage to the lens, suspensory 
ligament, and ciliary body in such cases. The 
posterior route was preferable as a rule, in 
that it offered the minimum risk except for 
small foreign bodies not lying against the cili- 
ary body. 

When x-ray localization was impossible, 
tiny foreign bodies were often removed by the 
anterior route without material damage. Intra- 
ocular foreign bodies as large as 4 mm. in 
diameter could usually be removed without 
enucleation, leaving a fairly good-looking al- 
though sightless eye. Intraocular foreign 
bodies 0.5 to 2 mm. in size generally left a 
useful eye after their removal. Is was the 
practice to make diathermy punctures prior 
to the scleral incision when the posterior route 
was chosen. Foreign bodies in the anterior 
chamber and iris were removed through a 
keratome incision at the limbus. Some sur- 
geons used a spinal puncture needle attached 
to a syringe; on producing suction a small 
foreign body in a traumatic cataract could 
thus be removed. 

Nonmagnetic intraocular foreign bodies in 
the vitreous offered greater difficulty in re- 
moval. If the vitreous was clear, the Thorpe 
ophthalmic endoscope or the biplane fluoroscope 
was used. Special grasping instruments were 
devised by Thorpe and Cross. 

Nonmagnetic foreign bodies anterior to the 
vitreous were removed by forceps through a 
corneal incision. If embedded in the iris, an 
associated iridectomy was done. Those in the 
lens were removed if and when the cataractous 
lens was extracted. If a nonmagnetic body in 
the eye was not easily accessible, it was left in 

Sympathetic ophthalmia following intraocu- 
lar foreign body injury occurred in 5 patients. 
Penicillin was used in two of these without 
avail. The injured eye was removed in all cases 
and useful vision was preserved in the sympa- 
thetic eye. 

In contrast to the experience in World War II, 
no case of blindness from sympathetic ophthal- 
mia was recorded in the American Expedition- 



ary Forces in 1917-18. Greenwood accounted 
for this in three ways : 

1. Enucleations were performed of eyes so 
badly injured that a useful eye could not be 

2. Less devasting injuries were treated ex- 
pectantly; often the wounds were sealed by 
a conjuctival flap with the result that healing 
took place without subsequent iridocyclitis. 

3. Enucleation was done in all cases of per- 
sistent iridocyclitis. 

The incidence of all types of eye diseases and 
injuries during World War II was as follows : 

Total ^72,347 

Diseases 58,972 


Battle casualties 979 

Nonbattle 12,396 

The number of eye injuries in battle casual- 
ties was not much greater than the number 
of cases of blindness resulting from war in- 
juries. A war wound affecting the eye alone 
was relatively rare. Further, in reporting a 
casualty who had multiple wounds only the 

«In World War I, out of 48,290 patients with war injuries. 1.54 
percent had eye injury. Of these, 0.8 percent were serious. 

major wound was recorded. Therefore figur^ 
reported for battle wounds excluded minor eye 
injuries associated with more serious v^onni^ 
of other parts of the body. Of all battle casual, 
ties, 1.07 percent were carried on the sick Us^ 
with the eye injury as the diagnosis of primarj- 
importance. It must be assumed that other eye 
injuries occurred and required treatment but 
were considered, for reporting purposes, to be 
of secondary importance. 

In a study of 901 nonfatal cases of heavier- 
than-air naval aircraft accidents it was found 
that 40 patients had minor injuries to one eye 
and 15 had minor injuries to both eyes. Four 
had major eye injuries to one eye and one had 
major injuries to both eyes. 

Out of every 35 nonbattle injuries, one was 
an injury to the eye. Of these injuries to the 
eyes, 2.9 percent resulted in blindness in one 
or both eyes. 

Diseases of the eye accounted for over four 
times as many admissions to the sick list as did 
eye injuries, but the admissions for eye disease 
included a considerable proportion of common 
conditions of slight severity. The ratio of 
blindness caused by disease to the total number 
of cases of eye disease was about 1 to 240 ; in 
other words, 0.4 percent of the patients with 
eye disease became blind. 

Chapter XIV 


Winchell McK. Craig, Rear Admiral (MC) USNR 

The Bureau of Medicine and Surgery recog- 
nized neurologic surgery as a specialty long 
before the beginning of World War II. In fact, 
on 7 December 1941, the first medical special- 
ist unit ^ to be activated was Neurosurgical 
Unit Number 54, which was immediately or- 
dered to the U. S. Naval Hospital, Corona, 
Calif. The staff of this unit included 3 neuro- 

Neurologic surgeons were ordered to duty in 
continental and extracontinental naval hos- 
pitals wherever they would be of most value. 
Realizing, however, that some naval hospitals 
were better equipped than others to cope with 
neurosurgical problems, the Bureau designated 
certain naval medical centers as neurosurgical 
centers. Such centers were established ^^^.the 
naval hospitals at Chelsea, Mass.ji^St. Albans, 
N. Y. ; San Diego, Calif. ; Phil^elphia, Pa. ; and 
Oakland, Calif., and a|:^,'the National Naval 
Medical Center, Betl^esda, Md. At these cen- 
ters, to which. <patients needing combined spe- 
cialized treatment were transferred, there were 
available consultants in orthopedic surgery, 
plastic surgery, maxillofacial surgery, ortho- 
dontia, and other specialties. 

The neurosurgeons closely cooperated with 
these consultants, and with the general sur- 
geons, in an attempt to rehabilitate the 


In the years between World War I and 
World War II, it was recognized that the brain 
and meninges could resist infection to a re- 
markable degree. Harvey Cushing, in World 
War I, reported that the mortality rate of 36.6 

^ The medical specialist units, of which there were 110, were 
i^nde up of U. S. Naval Reserve officers who were medical and 
surgical specialists. 

percent in craniocerebral injuries was prin- 
cipally due to infections such as meningitis, 
abscess, and encephalitis. Geoffrey Jefferson, 
then neurosurgical consultant in the British 
Emergency Medical Service, estimated the 
mortality to be 20 percent. The introduction 
of the sulfonamides and penicillin changed the 
prognosis for all types of wounds in World 
War II. Much of the information concerning 
the treatment of wounds . of the central ner- 
vous system stemn^d from the early experi- 
ences of theyiBritish. Brigadier Sir Hugh 
Cairns, Jtj^A.M.C, and his colleagues advo- 
cated -the use of sulfadiazine on the first day 
i^\the treatment of craniocerebral injuries and 
meningitis and as a prophylactic measure. The 
British also initiated the use of penicillin 
intrathecally in the treatment of meningitis 
caused by susceptible micro-organisms. They 
showed that in cellulitis of the scalp, osteo- 
myelitis of the skull, and infected brain fun- 
gus, the systemic administration of penicillin 
was of great value. 

Early in the war it was established that 
the use of sulfonamides and penicillin was in 
no way a substitute for meticulous surgical 
procedure, although in craniocerebral wounds, 
pathogenic organisms gained access to the 
subarachnoid spaces or ventricular system re- 
gardless of the care used. It was found, how- 
ever, that with the aid of the sulfonamides and 
penicillin complete debridement could be done 
and the craniocerebral wounds closed without 
drainage, the majority of them subsequently 
showing no evidence of infection. 

The use of antibiotics reduced the incidence 
of intracranial abscess to a very low percent- 
age. Advances in the treatment of those 
abscesses which did occur included the demon- 
stration of the safety with which one could 



wait until the abscess wall was well estab- 
lished, after which the abscess could be re- 
moved in its entirety without the occurrence 
of widespread encephalitis. 

Penetrating wounds of the head and retained 
missiles received a great deal of thought and 
were thoroughly investigated. It was found 
that removal of a foreign body from the brain 
within 12 hours reduced the incidence of fatal 
infection. Failure of the foreign body to reach 
the ventricle greatly reduced the likelihood of 
death from a fulminating infection. At first 
it was believed that an unsterile foreign body 
deeply embedded but not communicating with 
either the skin or ventricle would not cause 
a fatal infection unless the ventricle at some 
time was penetrated. Early in the war, re- 
tained bone chips, rather than retained mis- 
siles, were believed to be the cause of abscess 
of the brain. Later, the occurrence of an abscess 
of the brain about a missile, even though the 
bone chips had been completely removed, was 
frequent enough to direct closer attention to 
removal of the missile. Electromagnets pre- 
viously used to remove steel fragments were 
replaced, for the most part, by the simple pro- 
cedure of using a piece of magnetized steel 
held in a pituitary rongeur. Intracranial hema- 
toma was uncommon in missile wounds of the 

It was found that with the use of antibiotics, 
extensive reparative operations on the head for 
craniocerebral wounds could be delayed until 
the patient was transported to hospitals staffed 
and equipped for the treatment of such in- 

Early in the war, the use of tantalum and 
acrylic resin was recommended for repairing 
skull defects. Prior to this, cranial defects had 
been repaired with sheets of celloidin or vari- 
ous metallic substances, including silver, and 
by flaps from the outer table of the skull. The 
lack of tissue reaction made tantalum a safe 
metal for use in making repairs. 

It was recognized that the insertion of a 
tantalum plate would not relieve convulsive 
seizures. On the other hand, in patients in 
whom encephalography did not disclose evi- 
dence of a cystic or degenerating lesion, the 
insertion of a plate frequently relieved the 

posttraumatic headache. The frequent occuj. 
rence of convulsive seizures following cranio^ 
cerebral injuries was the source of a great deal 

of concern in the Navy, and in deterini 

the prognosis of penetrating wounds of 
head, the fact was not forgotten that 


seizures could appear weeks, months, or even 
years following the head injury. 

The British found that all kinds of 
wounds of the skull were followed by convu]. 
sions in 24 percent of patients, probably be- 
cause the underlying injury to the brain was 
more severe than that which occurs in injuries 
of the skull in civilian life. The British also 
found that, although convulsions were more 
certain to follow direct injury to the sen- 
sorimotor cortex than damage to some region 
at a distance from the rolandic area, the exact 
site of cortical trauma did not seem to have 
an important bearing on the occurrence of 
convulsions. The first seizure might take place 
within a few hours or as late as 20 years 
after the original injury, although the initial 
onset was usually noted during the first 2 

For the prevention of craniocerebral in- 
juries, Cairns perfected the protective helmet 
worn by motorcyclists in the British Army. 
The steel helmet worn by the American sol- 
dier and Marine furnished excellent protec- 
tion against such injuries, but it had not been 
designed with aircraft and tank personnel in 
mind and could not be used to advantage by 
them, mainly because of its size, shape, and 
weight. Colonel Loyal Davis (MC) AUS, con- 
sulting neurological surgeon in the European 
Theater of Operations, designed a close-fitting 
helmet that was made by molding pieces of 
acrylic resin to conform to the frontal, tem- 
poral, occipital, and vertex portion of the 
skull ; this was then covered with leather and 
lined with chamois and fleece. Such a helmet 
permitted movement of the head in all direc- 
tions, provided complete protection over the 
frontal and occipital areas, and weighed only 
18 ounces. Designed for the Army and adopted 
by Marine and Navy fliers early in the war, 
this helmet significantly reduced the incidence 
of craniocerebral injuries. 

Blast injuries occurring in the water were 



Qf great concern, and much experimental work 
;vas done at the National Naval Medical Cen- 
ter in analyzing these wounds and determin- 
ing whether some means of protection could 
be provided. In these injuries, cerebral lesions 
^vithout any wounds of the head were noted. 

Cairns, of the British Army, believed that 
the possibility of cerebral fat emboli had to 
5e considered, although they were not always 
found at necropsy. Another mechanism that 
undoubtedly produced brain injury was the 
change in velocity of the head following a 
blow. It was shown experimentally that the 
velocity behind the blow and the restricted 
motion of the brain within the skull were im- 
portant factors in cerebral trauma in closed 
head injury, because a type of shearing strain 
results when the brain lags behind the rota- 
tional acceleration forces. At the National 
Naval Medical Center this was demonstrated 
by experimental work wherein Incite plates 
were substituted for the calvaria in monkeys, 
permitting direct observation of the brain as 
the skull was subjected to blows of measured 
intensity. Motion pictures made at the rate of 
2,000 frames per second showed a very defi- 
nite rotational movement of the brain. 

The brain could also be observed through 
this Incite cap when certain gases were in- 
jected into the subarachnoid space. The effect 
of hypoxia, of oxygen, and of vasodilating 
chemicals could also be noted through the 
transparent acrylic resin. Some of these mon- 
keys were sent to Princeton University where 
research on ballistics was in progress, so that 
the explosive effect of the bullet within the 
brain could be observed. This experimental 
work was probably the greatest contribution 
to neurosurgery during the war because it 
showed without question the effect upon the 
underlying brain of force directed against the 
intact skull, and also the effect of penetrating 
missiles of different velocity. 


One of the great problems of war surgery 
has been the treatment of patients with in- 
juries to the spinal cord. The incidence of 
vertebral fractures involving the cord was 
high on shipboard and in landing operations. 

258015—53 18 

Another type of injury was the disintegration 
of the spinal cord that followed concussion due 
to the passage of projectiles, not through the 
cord itself, but in its neighborhood. This lesion 
of the spinal cord did not respond to any type 
of surgical treatment, but early in the war it 
was established that laminectomy should be 
done to insure that no fragments of bone were 
compressing the cord and producing disability. 
This was indicated because preservation of 
even a small amount of motion or sensation in 
the lower extremities permitted easier and 
more complete rehabilitation of the patient. 

In closed wounds, such as fracture-disloca- 
tion of the spine, the application of traction 
was frequently followed by improvement. In 
fracture-dislocation of cervical segments of 
the spinal cord, it became standard practice 
to apply traction early with Crutchfield tongs 
attached to the skull, or with a head harness 
to extend the neck. Decompressive laminec- 
tomy performed weeks or months after spinal 
cord injuries rarely benefitted the patient when 
there was evidence of a complete transverse 
lesion without subarachnoid block; neverthe- 
less its use should be considered. 

Open wounds always required the most care- 
ful debridement. It was common practice in 
World War II to remove all bone fragments 
and foreign bodies and cleanse the wound, 
without opening the dura in the potentially in- 
fected field. Dural rents were closed by suture 
or by the application of living fascial grafts, in 
order to stop the leakage of cerebrospinal fluid. 
Chemotherapy was of great assistance in deal- 
ing with the wounds of the spinal cord. 

The nursing of patients with injury of the 
spinal cord proved to be complicated. The 
use of indwelling catheters and regulated 
enemas aided in the prevention of decubitus 
ulcers. Tidal drainage was successfully used 
in some neurosurgical centers, while, in others, 
cystostomy was employed to empty the blad- 
der. Drainage with an indwelling catheter, the 
development of an automatic bladder, and 
transurethral section of the hypertrophied 
sphincter contributed to rehabilitation. 

The prevention of decubitus ulcers was 
found to depend on good nursing care. When 
they occurred in spite of adequate nursing 



care and nutrition, they were treated with the 
attention necessary to prevent further infec- 
tion. Excision of the ulcer and the use of free 
skin grafts or pedicle skin grafts hastened 

In the nutrition of patients the value of 

maintaining serum proteins and the albumin- 
globulin ratio at normal values was demon- 
strated repeatedly. A high protein diet pro- 
vided an average daily intake of about 2,800 


The establishment of efficient urinary func- 
tion was one of the primary goals in the care 
of these patients. Tidal drainage was used ex- 
tensively, although it required the attention of 
a medical officer, a nurse, and a hospital corps- 
man and was not a simple, self-regulating 
mechanism. It did, however, afford a means of 
continuing cystometric study and assisted in 
minimizing Ijladder infections. In spite of its 
drawbacks, it seemed to be the only certain and 
safe means of training the bladder for auto- 
matic function. Various methods of urinary 
drainage which were used in the early days 
by both the Army and Navy included (a) per- 
mitting the bladder to distend and overflow, 
(b) manual expression of urine, (c) perineal 
urethrostomy, (d) suprapubic cystostomy, (e) 
repeated urethral catheterization, and (/) an 
indwelling urethral catheter. 

Under favora])le conditions, automatic 
micturition developed after complete transec- 
tion at any level within the cord or cauda 
equina, appearing earliei* when the lesion was 
located between the seventh cervical and fifth 
thoracic segments. It did not develop in incom- 
plete lesions of the cord, although the effect 
of extravesical stimuli on the initiation of 
micturition may be quite similar in either a 
complete or partial transection. It occurred 
with remarkable regularity at intervals as long 
as 3 hours, but with very low efficiency as evi- 
denced l)y a large amount of residual urine. 
Automatic micturition will develop only when 
there is no mechanical obstruction of the blad- 
der and when the sphincter is capable of reflex 
relaxation. Automaticity will not develop when 
sepsis or calculi are present, or in patients with 
severe debilitation. 

Another complication encountered in the 
habilitation of patients with injuries of ^ 
spinal cord was the persistence of pain in 
extremities. This was treated in a number 
ways, including chordotomy, rhizotomy, 
the intrathecal injection of alcohol. The relea 
of abnormal reflex activity was treated by 
injection of alcohol and by resection of J 
motor root. Because each patient was an 
vidual problem, no general rules could be 
plied regarding the treatment of this compli 


One of the perplexing problems was rup. 
tured nucleus pulposus with its associated syn. 
drome of low back pain and sciatica. It soon 
became apparent that operations for the relief 
of such pain were unsuccessful in the majority 
of patients, and that they had to be returned 
to hospitals in the United States. 

A statistical study carried out at the U. S. 
Naval Hospital, Bethesda, Md., disclosed that 
only 62 percent of enlisted personnel returned 
to duty after operations for the relief of pain 
due to ruptured nucleus pulposus, whereas al- 
most 100 percent of otHcers returned to duty 
after the same operation. The procedure of 
choice was a limited type of hemilaminectomy 
which was introduced before the war. It was 
found that a certain percentage of patients 
who had low back and sciatic pain also had 
changes in the bony structures or other definite 
lesions such as spondylolisthesis. 


The treatment of peripheral nerve injuries 
during World War II was aided by experimen- 
tal investigation, planned and implemented 
through the Otlice of Scientific Research and 
Development of the National Research Coun- 
cil. Among the advances were: (1) Tarlov's 
work on the use of plasma glue to facilitate 
the union of nerve ends that could be approxi- 
mated without tension, (2) the study of the 
traumatic degeneration produced by the con- 
cussive effect of gunshot wounds in which the 
nerve trunks were not severed, (3) the de- 
velopment of new staining methods to demon- 
strate the different patterns of nerve regener- 



ation after end-to-end suture, (4) the use of 
autogenous and homogenous grafts, and (5) 
the evolution of electromyographic methods for 
the study of denervated and reinnervated 

One of the most important contributions 
made during the war in the treatment of in- 
juries of peripheral nerves was the observation 
that a second operation should be performed 
on patients in whom the injured nerves did 
not show any evidence of regeneration within 
3 months after primary suture. In a large num- 
ber of patients the second operation disclosed 
that the ends of the sutured nerves had be- 
come separated because of motion or tension. 
To determine whether or not regeneration 
was taking place, certain electrodiagnostic 
procedures were developed. The changes in re- 
sponse to galvanic stimulation which charac- 
terize the complete reaction of degeneration 
are hyperirritability of the muscle to galvanic 
stimuli, sluggishness of relaxation following 
the contraction wave, lessening of the ratio 
between the amperage necessary to produce 
tetanic contractions and the rheobase almost 
to unity, and increase in the efficacy of anodal 
closing stimuli to equality with cathodal 
closure. The practical application of electro- 
diagnostic methods permitted evaluation of re- 
generation at an earlier date than could be 
done by clinical observation. If, after sufficient 
time had elapsed following injury, the charac- 
teristics of denervation were not found by elec- 
trodiagnosis, the nerve was considered to be 
spontaneously recovering and operation was 
not required. If, after a severed nerve had 
been sutured, the characteristics of the de- 
nervated state were not found, it was assumed 
that recovery was taking place. When a suffi- 
cient time had elapsed after nerve injury for 
regeneration to have occurred, and the charac- 
teristics of denervation were found, operative 
intervention was necessary. 

One of the great problems in the treatment 
of nerve injuries was the fact that they were 
frequently associated with damage to bone, 
muscle, or skin. Thus it was apparent early 
in the war that the combined efforts of the 
plastic surgeon, the orthopedist, and the neu- 
rosurgeon were essential in treating peripheral 

nerve injuries, in order that any associated in- 
juries might be treated simultaneously. This 
eliminated a great deal of controversy with 
regard to the use of splints, the application 
of braces, and the delayed treatment of frac- 
tures. Results of treatment of injuries of 
peripheral nerves were more satisfactory in 
the neurosurgical centers where there was 
complete cooperation between the different de- 
partments. Physical medicine also played its 
part in the treatment of these injuries, the 
use of passive motion and massage of the ex- 
tremities contributing much to the preserva- 
tion of function of joints and muscles. 

The use of new staining compounds de- 
veloped during the war years revealed that 
after any nerve injury the mesodermal tissues 
are the first to react by proliferation. This 
proliferation occurs at the site of the lesion, 
and extends into the gap between the severed 
nerve segments, into the degenerated distal 
nerve segment, and into the perineurium and 
epineurium of the central segment. Regenerat- 
ing nerve fibers follow the path of proliferat- 
ing histiocytes and collagenous fibers. This 
observation appeared to be evidence against 
the generally accepted theory that the regen- 
erating distal segment of the end of a cut nerve 
exerts a chemotropic influence on regenerating 
nerve fibers growing out of the end of the cen- 
tral stump. Mesodermal tissue plays a pri- 
mary role in the organization of autogenous 
and homogenous grafts in laying down a scaf- 
folding that is followed by regenerating nerve 
fibers. Depending on the degree of survival of 
the mesodermal elements in the graft and the 
degree of necrosis that occurs, this scaffolding 
follows the original nerve structure or be- 
comes irregular, deviating, and confused in 
its course and thus influences the course and 
the efficacy of the regenerating nerve fibers. 

One of the most difficult problems in the 
treatment of peripheral nerve injuries oc- 
curred in patients with gunshot wounds in 
which the continuity of the nerve had not been 
interrupted. Extensive injury was found in a 
nerve near the site of trauma caused by a 
missile that had passed through the adjacent 
tissues without penetrating the nerve. It was 
difficult to realize that degeneration of long 



segments of a nerve could take place, both cen- 
trally and peripherally, as a result of this type 
of injury. 

Young and Medewar in England, and Tarlov 
in this country carried out a series of experi- 
ments by using concentrated blood plasma gel 
to unite the ends of divided nerves. This 
method of repairing nerves was given a clini- 
cal trial in the U. S. Naval Hospital, St. Al- 
bans, N. Y., where it was employed in one 
series of cases while in a parallel series suture 
with silk, nylon, or tantalum wire was used. 

Experiments on the use of different types 
of sutures were carried out at the National 
Naval Medical Center. It was found that those 
sutures which caused the least reaction in 
peripheral nerves were human hair, nylon, silk, 
and tantalum wire. The use of catgut was not 
advised because of the marked reaction of the 
nerve cells about the suture. 

The syndrome known as ''causalgia'' was one 
of the great problems in the treatment of in- 
juries to the extremities. Operations on the 
sympathetic nervous system with denervation 
of the affected limb were followed by relief 
of pain in a high percentage of patients. 

Among the advances in neurosurgery was 
the introduction of hemostatic agents such as 
''fibrin foam,'' a fractionation product of blood 
plasma, and ''gelfoam'' made from ordinary 


Certain neurosurgical operations have been 
greatly facilitated by placing the patient in 
a sitting or upright position. In some clinics, 
dental chairs were converted for use in these 
procedures; in others, elaborate appliances 
were made that could be attached to the oper- 
ating tables, or various special tables were con- 
structed for this purpose. 

Shortly after the beginning of the war, it 
became apparent that the hospitals of the 
Armed Forces needed an appliance that could 
be attached to an ordinary operating table. 
From a practical standpoint, this attachment 
had to be inexpensive and of relatively small 
size, and had to combine certain essential fea- 
tures so that it could be used by the Army as 
well as the Navy. Such an apparatus, known 
as the Craig headrest, was constructed at the 

National Naval Medical Center. This headrpt 
could be attached to the ordinary operatin 
table in use in the Army and Navy hospit^j^ 
and could be easily stowed away when not 
use. It proved valuable in performing opera 
tions on the brain and cervical portion of the 
spinal cord. 

One of the great objections to the use of 
the upright position for neurosurgical opera, 
tions had been the variations which occur in 
blood pressure during the operations, neces- 
sitating lowering of the patient's head from 
time to time in the course of the procedure 
The headrest in question obviated this draw- 
back, as the patient could be placed in the sit- 
ting position with the feet and legs elevated 
to the level of the head. As a further precau- 
tion, it was found that splinting the vascular 
bed of the lower extremities had a stabilizing 
effect on the blood pressure. It was noted that 
if the legs were wrapped in ordinary bandage 
of one thickness from the ankle to the groin, 
the blood pressure would not vary even when 
the operation was carried out under general 
anesthesia, unless there was an extraordinary 
loss of blood. 


The limited number of adequately trained 
neurosurgeons in the Navy made it important 
that they be used wisely. The Surgeon General, 
Vice Admiral Ross T Mclntire, was cognizant 
of this fact and suggested the formation of a 
flying neurosurgical unit to be stationed at the 
National Naval Medical Center. This unit, au- 
thorized by the Bureau in July 1942, was to 
be ready to answer emergency calls up and 
down the East Coast in the event of bombing 
by the enemy. Admiral Mclntire realized that 
adequate operations on the brain, peripheral 
nerves, and spinal cord required special equip- 
ment not available in all service hospitals and 
also realized the importance of a trained sur^ 
gical team. 

Experience had shown that in the manage- 
ment of injuries of the brain and spinal cord, 
transportation of the wounded to the nearest 
hospital where adequate care was available re- 
sulted in a lower mortality rate and a more 
satisfactory convalescence. Because it wa? re- 


alized that bombing of the Atlantic coast might 
j-esult in a great number of central nervous 
^vstem injuries at a place where adequate 
neurosurgical care was not obtainable, the 
flving neurosurgical unit was maintained 
throughout the war to augment the staff and 
equipment of any hospital along the coast in 
an emergency. It not only assured specialized 
surgical care in widely separated areas, but 
greatly reduced the need for a neurosurgical 
^eam in every hospital. 

The neurosurgical flying unit consisted of a 
neurosurgeon, an assistant neurosurgeon, an 
anesthetist, and a hospital corpsman. The en- 
tire equipment was so assembled that the four 
men comprising the team could transport it 
from the hospital to the flying field in a sta- 
tion wagon or ambulance, carry it to the plane, 
and arrange for transferring it to the hospital 
where needed. It consisted of a small portable 
electrosurgical unit, a fiber case for neuro- 
surgical instruments, a small portable suction 
unit, and a portable operating table. The 
carrying cases for supplies of necessity had 
to be light and easily handled, so Marine 
sea bags with handles were used. These con- 
tained towels, linens, gloves, pans, gowns, and 
gauze. A list of the contents was typed on 
linen, which was sewn on the flaps. Operating 
room supplies such as gowns, drapes, and 
towels were packed in three sea bags. Neces- 
sary solutions such as plasma, serum albumin, 
saline solution, and pentothal sodium and 
equipment for intravenous administration were 
packed in similar bags. Four other medical kits 
containing all necessary incidental items for 
proper surgical care were also included. The 
total weight of these items is shown below. 

Weight of equipment 

1 first-aid kit 12 i 

1 suction apparatus 23 

1 fiber case of instruments 73 

1 operating table 87 

1 electrosurgical unit 70 


Weight of equipment 
( pounds ) 

1 first pack 50 

1 second pack 52 

Total 3671 

The supplies in the Marine sea bags, the 
electrosurgical unit, the suction apparatus, the 
fiber case of neurosurgical instruments, and 
the portable operating table were sufficient to 
carry out emergency neurosurgical procedures 
whether in an emergency room, in a school- 
house, or in temporary hospital quarters. Forty 
minutes after the unit was alerted, the instru- 
ments could be sterilized, the supplies as- 
sembled, and the unit underway to the airport. 

No history of any period is complete with- 
out comment on the mistakes that have been 
made. Among the outstanding errors made 
during World War II, were lack of cooperation 
and immobility of the surgical specialists. Dur- 
ing peacetime, the number of surgical special- 
ists needed to care for civilians is not so great 
as it is in time of war. In the tables of organi- 
zation of naval hospitals other than neurosur- 
gical centers and hospital ships, some surgical 
specialties, particularly the specialty of neuro- 
surgery, should be eliminated. Neurosurgical 
teams and consultants should be mobile. Re- 
ports have indicated that the incidence of in- 
juries to the central nervous system during 
World War II was about 10 percent of all 
casualties, and it is a waste of time and talent 
to immobilize a neurosurgeon to take care of 
10 percent of the wounds which come to a 
naval hospital. It might be well to create neuro- 
surgical teams that could go wherever needed 
and be available as indicated. In another war 
the neurosurgical consultant in a given area 
should be responsible for the neurosurgical 
activity in the naval hospitals of that entire 
region. Only in this way will it be possible to 
take care of the neurosurgical wounds satis- 
factorily and supervise the rehabilitation of 
patients who have sustained injuries to the 
central nervous system. 


Chapter XV 

Peripheral Neurosurgery 

William K. Livingston, Capfain (MC) USNR (Retired) 

Most of what is known about the treatment 
of nerve injuries was learned during a war. 
It is only then that a sufficient number of these 
injuries can be grouped together for the inves- 
tigations necessary to establish criteria for 
more accurate diagnosis and better surgical 
techniques. The first effort in this direction 
was made during the Civil War when the Sur- 
geon General of the U. S. Army set aside Tur- 
ner's Lane Hospital in Philadelphia for the 
study of treatment of nerve injuries. 

No adequate analysis of the nerve injuries 
that occurred in World War I has ever been 
made, yet the evidence has clearly indicated 
that this group of casualties was of consider- 
able medical and economic importance. Long 
before World War II began, it was known that 
approximately 10 percent of all war wounds 
were complicated by serious injury to one or 
more major peripheral nerves, and that the 
proper care of these patients required special- 
ized training in diagnostic and prognostic 
methods, in addition to the most careful surgi- 
cal technique. 

In World War I, nearly 45 percent of the 
nerves sutured failed to recover any function. 
Nerve injuries have always required long 
periods of observation and an inordinate 
amount of attention. These facts indicated that 
the economic importance of nerve injuries re- 
sulting from war wounds is much greater than 
the number of such injuries would suggest. 

The story of the development of peripheral 
neurosurgery at the U. S. Naval Hospital, Oak- 
land, Calif., which follows, is illustrative of 
much that was learned. The first group of pa- 
tients with nerve injury reached the hospital 
from the fighting front on an average of 5 
months after they had been wounded. The prin- 
cipal reason for this delay was the critical 

shortage of transports in the first year of the 
war. It was impossible to bring the patients di- 
rectly to the mainland, so they were trans- 
ferred from one naval hospital to another in 
the Pacific Area until transportation to the 
United States became available. 

An example of the problems presented by 
the patients with nerve injuries is one who 
had an ischemic paralysis with severe causal- 
gia in his left arm and hand. He had been 
wounded when his ship received a direct hit, 
sustaining wounds of his back and the pos- 
terior aspect of his left shoulder. When re- 
ceived for treatment at this hospital, his left 
hand was cold, cyanotic, functionless, hyper- 
esthetic, and the source of deep, burning pain. 
There was evidence of an arteriovenous an- 
eurysm and a large, firm swelling just above 
the inner condyle of the humerus. The hard 
mass was thought to be an organized hematoma, 
but the roentgenogram and subsequent explor- 
ation revealed it to be an 11-ounce rivet. Ap- 
parently the rivet had been driven through the 
man's shoulder and down the inner side of the 
upper arm, to lodge near the humeral condyle. 
Surgical excision of the arteriovenous an- 
eurysm and removal of the rivet did not relieve 
the patient's pain. It was months before this 
could be brought under control. Three explora- 
tory operations were done before the injury 
was finally demonstrated to involve the nerve, 
from the elbow region to high in the axilla. 
The median nerve was the last nerve trunk to 
be sutured. When the patient was finally dis- 
charged from the service 2 years after being 
wounded, it was still too early to be sure that 
the last nerve anastomosis would be successful 
because considerable disability still remained 
in his hand. 

At this hospital many patients with nerve 



injuries were not examined by a neurosurgeon. 
Nerve lesions that complicated fractures v^ere 
usually treated by the orthopedic surgeon, and 
the same situation held true on other specialty 
v^ards. Some of these nerve lesions w^ere very 
skillfully handled, others received the same 
casual treatment they usually received in civil 
practice. The intern or surgeon who first ex- 
posed the lesion would suture the nerve; the 
suture material and technic depending upon 
what was at hand. Often nerve injuries were 
unrecognized, or were neglected for long in- 
tervals because the specialist was primarily 
interested in some other phase of wound heal- 

An orthopedic surgeon whom I encountered 
one day on the hospital ramp, said to me : 'Tm 
sorry you weren't in the surgery this morning 
when I changed the cast on a fractured femur 
of one of my patients. I think his sciatic nerve 
has been severed, and I wanted to consult with 
you about it." 

I asked when the man had been wounded and 
was told that he had been struck by a bullet 
during the early fighting on Guadalcanal, more 
than 6 months previously. I then asked how 
long it had been suspected that a nerve lesion 
existed, and whether or not anything had been 
done about it. 

*^Well," he replied, "Fve suspected that the 
nerve was gone because of the paralysis of his 
foot, but I wanted to get a solid union of the 
fracture before investigating the nerve lesion. 
The bone is quite solid now, and I believe this 
man will have a fine result after a very serious 
type of fracture." 

Fortunately, this casual attitude toward a 
nerve lesion was not the usual one. Most of 
the medical officers were alert for evidence of 
nerve involvement in their patients, and were 
glad to share the responsibility of care with 
some one interested in this type of lesion. 

Progress in peripheral neurosurgery began 
when the members of the staff realized the de- 
sirability of segregating patients with nerve 
injury for study and treatment. When some 
other complication such as a fracture was pres- 
ent, the patient was often left on that specialty 
ward, and the neurosurgeon shared the respon- 
sibility for treating the nerve disability. 

The major difficulty in treating patient^ 
with nerve injury was that it was often impos^ 
sible to retain them on the ward long enoug}^ 
to complete the diagnostic procedures and the 
necessary surgical explorations, to say noth 
ing of the follow-up studies they required 
There was an enormous pressure for more beds 
to receive the increasingly large numbers of 
patients arriving from the Pacific. To meet 
this demand, the patients were moved to 
nearby convalescent hospitals at Santa Cruz 
and Yosemite, or to the more distant hospitals 
in Glenwood Springs, Colo., and Sun Vallev 
Idaho, or to naval hospitals in other parts of 
the United States. Ward medical officers were 
expected to transfer any patient fit for travel. 
The fact that the patient might be in the midst 
of prognostic studies or just recovering from a 
surgical exploration made no difference; if 
moving the patient would not jeopardize his 
life, he went. The majority of our patients sent 
elsewhere were rarely seen again by the origi- 
nal physician. Regrettable incidents that oc- 
curred among the patients who returned 
might have been averted if there had not been 
so much pressure to clear patients from the 

During the development of a Peripheral 
Nerve Service at this hospital, there were two 
principal factors that made it difficult to pro- 
vide adequate care for the patient with a nerve 
injury. The first of these was the rapid turn- 
over of patients and the second was the lack 
of continuity of service among staff personnel. 
By using double-decked bunks for half of our 
ward, we could accommodate approximately 
70 patients in the neurologic department. The 
remainder of the patients with nerve injury 
were scattered over the hospital. 

The routine tasks of the ward represented 
only a small part of the real work of the 
clinic; in addition to the maintenance of the 
records, there were detailed histories to record, 
examination and mapping of sensory and sweat 
patterns to carry out, diagnostic and prognos- 
tic testing to be done, and periodic re-exami- 
nations for each patient. All of these activities, 
except the most routine, required special skill 
and training on the part of the examiner; 
otherwise the findings were not worth record- 



jjig in the patient's clinical record. Whenever 
possible, a medical officer was assigned to the 
peripheral Nerve Clinic to assist with the 
^y^yd work. About the time this assistant had 
acquired sufficient training to make his obser- 
vations x^eliable, however, ^'orders'' would ar- 
rive transferring him to some other hospital. 
There were also interns in training at Oak 
Knoll, and one was assigned to our ward for 
a period of 2 weeks. The continuity of service 
among the nurses and corpsmen assigned to 
the ward rarely extended beyond a month 
QY two. A nurse who had evinced an aptitude 
and interest in the work might be called away 
to do night duty or work in the hospital laun- 
dry, or a corpsman just completing his train- 
ing in mapping sensory or sweat patterns 
would be transferred to another ward or to 
work in the galley. 

Yet, in spite of the rapid turnover of pa- 
tients and staff, we discovered some interest- 
ing facts. The first of these was that plaster 
casts, used to support paralyzed muscles in the 
uncomplicated case of nerve injury, did more 
harm than good. Of course, there were other 
complications such as a fracture that required 
rigid fixation of the limb, or a patient with 
extensive wounds of the soft parts might re- 
quire a plaster cast for comfort and safety 
during transfer to another hospital. Plaster 
casts were applied routinely to patients with 
uncomplicated nerve paralysis. Physicians had 
been taught that paralyzed muscles must be sup- 
ported because otherwise the opposing muscles 
would develop a contracture, or the paralyzed 
muscle would be hopelessly stretched. There 
is an element of truth in both of these claims, 
although not enough to justify the routine em- 
ployment of plaster-cast fixation for long 
periods. Because of this teaching, however, and 
because they lacked more suitable splints, the 
medical officers in the Pacific area were using 
plaster casts to support paralyzed muscles. 
During the months our patients had been 
shifted from one Pacific area hospital to an- 
other, the patients never stayed long enough 
in one hospital to permit thorough investiga- 
tion of the need for cast fixation. If the cast 
became soiled, it was removed and a new one 
applied. By the time some of the patients 

reached a hospital in the United States their 
limbs were wasted and their joints stiffened. 
Sometimes, the tissue damage caused by the 
cast was more serious than the nerve injury 
and required months of physical therapy treat- 

One of the first routine orders on our serv- 
ice was to bivalve all plaster casts as soon as 
the patient was admitted to the ward. This 
permitted an adequate examination of the 
limb. In most instances cast fixation could be 
discarded at once or physical therapy treat- 
ments started while the patient was still sup- 
ported in the bivalved cast. Our reaction to 
cast fixation extended to all forms of splinting. 
We questioned whether even the lightest splint 
was justified and ultimately rejected all splint 
support in every uncomplicated nerve paralysis 
except that of the peroneal nerve. The bed pa- 
tient with foot-drop was protected from the 
pressure of bed covers, and passive motion of 
the foot was encouraged. The ambulatory pa- 
tient with foot-drop was provided with a light 
spring support attached to his shoe that he 
could wear or not as he chose. If he thought 
that it prevented his stumbling, and concealed 
his disability better, he was permitted to wear 
the splint. If he didn't mind ''slapping the 
deck'' with his foot as he walked, or if he wore 
a Marine shoe which lessened the drop of the 
foot by its support of the ankle, he was not 
required to wear a splint (patients with per- 
oneal and radial nerve paralysis were ex- 
cepted). We taught patients with wrist-drop 
to carry their hands at their sides and use 
the hand in the supinated position. These men 
undoubtedly made much more use of the af- 
fected hand, and a casual visitor seldom no- 
ticed the defect. Evidence that the lack of 
splint support to paralyzed muscles was harm- 
ful was rarely noted. We were convinced that 
the absence of splints favored a greater ac- 
tivity and a better morale, at the same time 
maintaining the tissues of the limb in a more 
normal state than with a splint. 

The second observation of interest was that 
many patients whose history and health rec- 
ords indicated that their nerve paralysis had 
been complete for weeks or months, while 
they were in the South Pacific, were showing 



signs of spontaneous recovery by the time 
they reached Oak Knoll. One of the firm con- 
victions I had had when I entered active serv- 
ice in the Navy was that all nerve lesions 
should be surgically repaired as early as pos- 
sible after injury. When a complete loss of 
function of a nerve exists in conjunction with 
an incisional wound, one is justified in assum- 
ing that the nerve trunk has been severed and 
that immediate surgical intervention is indi- 
cated. However, wounds caused by high- 
velocity missiles are capable of paralyzing 
nerve function in many ways other than by 
complete transection of the nerve trunk. 

A high-velocity missile releases an enormous 
amount of kinetic energy as it passes through 
human tissues, and produces in its wake a 
large pulsating cavity. Nerves at some distance 
from the path of the projectile may sustain 
injury by the combination of the effects of im- 
pact and the stretching and tearing of the 
tissues during the phase of cavitation. The 
damage inflicted may be sufficient to paralyze 
all function and interrupt the nerve fibers and 
yet leave the nerve trunk in anatomic con- 
tinuity. A fusiform neuroma usually develops 
at the site of the damage and this offers vary- 
ing degrees of obstruction during the regenera- 
tion of fibers. Many injuries of this type fail to 
produce as serious a distortion of the intra- 
neural fiber patterns as that caused by the 
most painstaking nerve suture. In some pa- 
tients who had begun to regain function, the 
degree of recovery promised to be more rapid 
and complete than we could have hoped for 
after resection of the local neuroma and an 
end-to-end anastomosis of the nerve trunk. 

Without this war experience of spontaneous 
recovery in damaged nerves, many lesions 
would have been resected that might better 
have been left alone. Because of this experi- 
ence a very conservative attitude regarding 
these local lesions was assumed. This led us 
into error at times. Not infrequently surgical 
exploration was delayed in the belief that spon- 
taneous regeneration was taking place, only to 
be required later when it was found that the 
damage to the nerve trunk had been more seri- 
ous than we had realized. Such errors, how- 
ever, usually meant no more than a delay in 

the surgical resection and suture, while an 
early resection of the lesion might have meant 
a less satisfactory end result. It will be impos 
sible to evaluate the results of this conserva. 
tive policy until follow-up studies can be com. 
pleted, but the impressions gained from our 
observations suggest that the policy is a sound 

The question of what to do with lesions in 
continuity imposed a heavy responsibility on 
the surgeon. Should the lesion in continuity be 
resected or not? It might be too early for re- 
generating fibers to have reached their ter- 
minal distribution even if they had been suc- 
cessful in passing the damaged nerve segment. 
For this reason clinical examinations and elec- 
trical tests of the paralyzed muscles would not 
help the surgeon in making his decision. Was 
there any other method by which nerve fibers 
growing through a neuroma could be demon- 
strated? It was thought that an oscillograph 
might aid in the surgery. If nerve fibers were 
growing through the neuroma it might be 
feasible to demonstrate action potentials set 
up by electrical stimulation passing across the 
damaged segment. 

Lt. Comdr. Henry Newman was assigned to 
carry out all the electrical testing. His knowl- 
edge of electronics enabled him to successfully 
record action potentials in the surgery and to 
construct a testing instrument to determine 
strength-duration curves, chronaxie, and 
* 'tetanus-twitch ratios" as well as the usual 
RD reactions. 

The Peripheral Nerve Clinic at Oak Knoll 
reached its maximum efficiency about the time 
the war ended. At that time the operative 
schedule was full, and each of the many ac- 
tivities of the clinic was at its best. Detailed 
case records had been collected on more than 
1,200 major nerve lesions, the great majority 
of which were caused by high-velocity missile 

One of the most promising of our clinical 
investigations concerned changes in the sen- 
sory pattern after the permanent loss of func- 
tion in a mixed nerve. It is a well-known fact 
that the anesthetic zone appearing immedi- 
ately after such a nerve has been cut begins 
to shrink in size long before regeneration 



ild take place. The accepted interpretation 
^^.^5 that sensory fibers supplying adjacent 
areas normally overlap one another, and that 
^'hen one nerve is cut the overlapping fibers 
Qf the neighboring nerve gradually recover 
their ability to transmit sensory impulses. Ac- 
cording to this interpretation, there is no ac- 
tive in-growth of new fibers from the neighbor- 
ing nerve. The ''isolated" supply of the cut 
j^erve, that zone exclusively supplied by it, v^as 
supposed never to recover sensibility unless 
that nerve regenerates. For instance, the distal 
part of the index finger is believed to repre- 
sent the ''isolated'' supply of the median nerve, 
so that recovery of sensibility at the tip of the 
index finger was interpreted as incontro- 
vertable evidence that the median nerve is 
regenerating. On the other hand, animal ex- 
perimentation carried on in England has shown 
that in a rabbit's leg there occurred an active 
ingrowth of new sensory fibers from neighbor- 
ing nerves to provide a denervated zone with 
sensation. Our clinical observations seemed to 
show that in human subjects as well as in 
the rabbit the factor of "invasion" contributed 
to the gradual shrinking of anesthetic zones in 
exactly the same way that skin grafts become 
innervated. Because this observation is of some 
clinical significance, the following brief sum- 
mary of a case is recorded: 

A marine wounded at Vella Lavella on 24 
August 1943, sustained extensive damage to 
h?s right median nerve when a large piece 
of shrapnel plowed obliquely up through his 
forearm. The usual pattern of sensory and 
motor loss characteristic of median nerve 
paralysis supervened. Three attempts were 
made to secure an end-to-end anastomosis of 
this damaged nerve, and when these attempts 
had failed a frozen-dried graft of human nerve 
was used to bridge the remaining gap. During 
2 years of observation, the zone of complete 
anesthesia steadily diminished in size until at 
the end of the time there was quite a satis- 
factory recovery of sensibility, even at the tip 
of the index finger. If this man had had a 
simple suture of his median nerve we would 
have rated his sensory recovery as "satisfac- 
tory" and would never have questioned the 
evidence that the median nerve had regener- 

ated. Yet, because we were inclined to question 
the efficacy of any nerve graft, this man was 
subjected to further investigation. An infiltra- 
tion of 2-percent novocaine into the median 
nerve, both above and below the graft, failed 
to alter in the slightest degree the sensory 
status of the hand, while novocaine block of 
the ulnar nerve rendered the fingers completely 

It should be clear that this fact of active 
"invasion" of sensory fibers into denervated 
areas has a clinical significance. The one great 
task remaining to be done in relation to periph- 
eral nerve casualties is to carry out a fol- 
low-up study of the results of nerve surgery. 
It is important for us to know the capacity to 
regenerate of each major nerve, and the in- 
fluence that the level of the interruption and 
the technique of anastomosis may exert on the 
recovery of function. The success of a nerve 
suture will be judged by the degree to which 
motor and sensory function is restored. In 
order to avoid erroneous conclusions based 
on these studies of end results, the examiner 
must make a careful distinction between true 
regeneration of the nerve under question and 
the invasion of sensory fibers from neighbor- 
ing nerves. 

Several obvious lessons can be drawn from 
this discussion. Insufficient importance was 
given to peripheral neurosurgery in prelimi- 
nary planning, and valuable time was lost be- 
fore special clinics were established. Even 
then there was at first little continuity of serv- 
ice, so that clinic personnel were continually 
being transferred. There was a general lack of 
appreciation of the importance of early atten- 
tion to nerve injuries by specialists, of the 
danger of transferring certain patients, of the 
need of a long follow-up study of each case, 
and of the great value of research and investi- 
gations based on the abundant material avail- 

To make this criticism constructive, one 
should show how preliminary planning might 
improve the status of peripheral neurosurgery 
in any future war. No better method for this 
suggests itself than outlining the program for 
the care and study of nerve casualties which 
was carried out by the British. 



In England, during World War II, a cen- 
tral body was made responsible for the treat- 
ment of all nerve casualties, instead of having 
each branch of the military handle the prob- 
lem as it saw fit. This Peripheral Nerve In- 
juries Committee of the Medical Research 
Council was composed of experts from various 
parts of England. Its members formulated 
policies, authorized research investigations, 
and supervised follow-up study of all nerve in- 
juries, whether they occurred among civilians 
or military personnel. 

In June 1941, this Committee adopted a com- 
prehensive program whereby it was possible 
to follow each patient throughout his period 
of active treatment, and for at least 3 years 
thereafter. They provided a system of uniform 
report forms for recording histories, evaluat- 
ing nerve recovery, and describing the find- 
ings of surgical exploration of nerve lesions. 
The Committee encouraged many research 
projects and saw that contributions relating to 
nerve surgery or the more fundamental aspects 
of nerve physiology w^ere made available to 
every worker in this field. 

Three great centers for the special care and 
study of nerve injuries were developed, one at 
Winwack, another at Pyrford and Botleys 
Park, and the largest one at Oxford in the 
Wingfield-Morris Orthopedic Hospital. Two ad- 
ditional centers were established later. Be- 
cause of the location of these centers in vari- 
ous parts of the country, nerve casualties could 
be sent to a hospital near their home. This 
made it possible to shorten the period of hos- 
pitalization for many of the ambulatory 
patients who could be sent home between 
operations or special investigations, thus free- 
ing a hospital bed until it became time to re- 
call the case for further observation. 

Even after a man was discharged from serv- 
ice and his pension rate established, he was 
required to report at definite intervals to a 
member of the Peripheral Nerve Injuries Com- 
mittee. His ability to draw his pension was 
made dependent upon his reporting. This ar- 
rangement ensured an adequate follow-up 

study of each case and enabled the Committ 
member to send any man back to the hospj^.^ 
if further treatment or investigation was ind^ 
cated. At each of the centers, the essentia] 
nerve surgery was performed by men 
special training in this work. The work of 
surgeon was supplemented by that of a trained 
corps of physicians who made the diagnostic 
and prognostic examinations which served to 
guide the surgeon in his operative decisions. To 
complete the program, the Peripheral Nerve 
Injuries Committee fostered research at the 
centers. The investigations in the clinics were 
supplemented by laboratory research into the 
fundamental problems of nerve physiology and 

The details of the beautifully coordinated 
British program were reported to the Na- 
tional Research Council in 1943. Most of this 
information had, however, been available to 
the military authorities in this country since 
1941, and it is hard to understand why the 
Navy should not have incorporated into their 
own program the best features of the British 
plan, particularly after it was called to their 
attention in 1943. In its special planning for 
nerve casualties, the Army apparently did bet- 
ter than the Navy. At least, they set up a good 
program for the training of young surgeons 
in peripheral neurosurgery, established 20 
centers for the treatment of nerve injuries, 
and developed a ''Peripheral Nerve Registry*' 
with uniform records for all the nerve anas- 
tomoses performed by Army surgeons, long 
before the Navy showed any active interest in 
adopting similar measures. Yet, as far as I 
can judge, neither the Army nor the Nav}' 
even approximated the coordinated activities 
of the Peripheral Nerve Injuries Committee in 
England in handling this important group of 
war casualties, or in fully utilizing the avail- 
able clinical material in the advancement of 
scientific knowledge. 

If the United States ever again becomes 
involved in a war, more adequate prepara- 
tions should be made for the care of patients 
with nerve injuries. 

Chapter XVI 

Thoracic Injuries 

Howard K. Gray, Capiain (MC) USNR 
\ ' Joseph P. O'Connor, Commander (MC) USNR 
Herbert D. Adams, Commander (MC) USNR 
James D. Fryfogle, M.D. 

The opportunities presented during World 
War II for the treatment of thoracic injuries 
were without parallel in medical history. Many 
of the barriers that stayed the hand of the 
surgeons in World War I had been surmounted. 
Infection, which killed more men in the Civil 
War than did bullets, was no longer the prin- 
cipal cause of death. Wounds of the thorax 
comprised approximately 6 percent of all war 
wounds. The total mortality rate for wounds 
averaged about 8 percent, but those of the 
thorax accounted for 32 percent of this mor- 
tality rate. Thus, although there was a rela- 
tively low incidence of thoracic wounds there 
was an extremely high mortality rate in this 
group of injuries. 

Table 31 shows the mortality rate in patients 
with thoracic wounds in wars prior to World 
War 11. The exact rate for thoracic injury 
is not known, because the nature and extent of 
the wounds of many men killed in combat could 
not be determined. 

Table 31. — Mortality rate from thoracic wounds in 
wars prior to World War II 




•ean War _ 


riean Civil War 


.('o-Prussian War 

24. o 

lish-Amcrican War 

War _ 


Id War I 


-Japanese War _ _ _ 


In World War II, chemotherapy, a clearer 
concept of the abnormal physiologic processes 
associated with thoracic injury, and adroit and 
audacious surgical treatment served not only 

to preserve life but also to restore physiologic 
function to normal or near normal in what 
had previously been a fatal injury. The interval 
between injury and treatment, which, when 
prolonged, made surgical correction impotent, 
was greatly shortened by having skilled corps- 
men and medical officers in the forward areas. 
Immediate transfusion of blood or plasma, 
accurate evaluation by frontline medical offi- 
cers of the type of treatment indicated, and 
rapid transportation to a well-equipped hospital 
in which every known method of treatment 
could be prescribed w^ere factors that contrib- 
uted greatly to the lowered mortality rate 
and the shortened period of morbidity. Much 
credit should be given to the Bureau of Medi- 
cine and Surgery administrative plan of segre- 
gating thoracic injuries, in order that the 
exacting care and the diagnostic and therapeu- 
tic measures needed to achieve the best results 
would be available. 

Primarily, we were concerned with three 
questions: (a) What conditions must we be 
prepared to treat? (6) When do we treat them? 
and (c) How do we treat them? The answers 
to all three questions in an individual patient 
were modified by the location of the patient 
and by the availability of personnel and equip- 
ment. All units were prepared to treat shock, 
control hemorrhage, and institute measures to 
combat infection and support respiratory func- 

Infection, — For practical purposes, all 
wounds of the chest were considered to be po- 
tentially infected. Penetrating wounds usually 
had been contaminated by foreign bodies, such 
as bullets, metallic fragments, clothing, dirt, 



or skin. Blast or crush injuries without pene- 
tration often resulted in infection of the pleural 
space because of the establishment of a com- 
munication with a traumatized lung, bronchus, 
or esophagus. The empiric use of sulfonamides 
and antibiotics, applied locally and adminis- 
tered parenterally to ensure a protective level 
in the blood, proved effective. 

No single organism appeared to be respon- 
sible for the infectious processes usually 
observed. Those most commonly obtained on 
culture, especially in chronic infection, were 
alpha, beta, and gamma strains of hemolytic 
streptococci. Staphylococcus avreus, and P.scv- 
domonas aeruginosa. Less frequently found 
were Escherichia coli, Aerobacter aerogenes, 
and Proteus vvhjans. Infections that went on 
to suppuration commonly contained anaerobic 
streptococci, fusiform bacilli, and spirochetes 
(Borrclia vincentii) . The presence of such 
virulent pathogens plus the contamination of 
the wound by an endless variety of local organ- 
isms made the institution of measures to com- 
bat infection mandatory at the earliest moment. 
The value of the sulfonamides and antibiotics 
in acute surgical infections is now well estab- 
lished, and adequate dosage at the onset often 
thwarted the development of the more compli- 
cated mixed chronic infections that demanded 
more specific therapy. 

When treatment tvas to be given. — The ques- 
tion of when to treat thoracic injuries was of 
the utmost importance. This management could 
not be reduced to a simple formula but was 
governed by the presence or absence of various 
factors in the individual patient. Each member 
of the "team" treating these injuries w^as made 
aware of the facilities and his capabilities. The 
''team" consisted of all personnel who aided 
the patient from the time of injury until his 
final discharge from medical care. 

Corpsmen who first saw the patient were 
taught that sucking wounds should be closed 
immediately with a dressing large enough to 
stop the sucking noise ; that a ''stove-in" chest 
should be bandaged snugly; that the wounded 
man should be urged to cough if he had mucus 
in his throat, and that he should be transported 
in a sitting position if he had difficulty in 
breathing when lying down. 

When the patient was seen at the d' 
clearing station, immediate appraisal of 4.1. 
extent of the injury was made. The 

. . Medical 

officer's first concern m the seriously in 

racic casualty was how best to prepare the 
patient for safe evacuation to a forward hos 
pital or ship. 

Early therapy in advanced areas. — Morphine 
was administered for the relief of pain, and 
fluid replacement therapy was begun to ensure 
adequate volume of circulating fluid. Nothing 
was as effective as whole blood when loss of 
blood had occurred, but plasma was often the 
only substance available. The first-aid measures 
instituted by corpsmen were checked. Open 
chest wounds were sealed securely with petro- 
latum dressings, the stability of the chest wall 
was ensured by strapping, and if a suction 
apparatus could be improvised an adequate 
airway was obtained by cleansing the mouth 
and throat, including the laryngeal area and 
upper part of the trachea. Early and rapid 
evacuation of these patients was given high 
priority. Evacuation by air was contraindi- 
cated for some because patients with respira- 
tory embarrassment did not tolerate the rarified 
atmosphere or the increase in volume of a 
pneumothorax that occurred when high alti- 
tude was attained. 

Definitive the rap y. — Upon arrival at a hos- 
pital, the patient's status was re-evaluated 
without delay. The physical examination in- 
cluded roentgenograms, if the patient's con- 
dition permitted, and an accurate estimation 
of the features of the thoracic wound. Imme- 
diate attention was given to those patients 
who, in spite of treatment, instituted in the 
forward areas, had shock, sucking wounds, 
pain in the chest wall, anoxia, or mechanical 
difficulties in breathing. To determine those 
patients for whom immediate surgical treat- 
ment was mandatory, accurate diagnosis was 

The large majority of wounds were of two 
types : those resulting from penetrating frag- 
ments and those resulting from concussion or 
blast injuries. In the latter group, unless signs 
of continual blood loss, perforation of a viscus, 
or tamponade were present, surgical treatment 
was delayed. Patients with pulmonary and 



i cardiac contusion tolerated poorly either anes- 

1 thesia or surgical measures. 

I In penetrating wounds, the extent of the 
injury was most important. It was essential 
to plot as accurately as possible the course of 
the missile. Possible deflection from bony sur- 
faces, presence or absence of a wound of exit, 
and the position of the patient when struck 
were considered. It was necessary to determine 
if the injury was limited to the thorax, or if 
structures within the abdomen or neck were 
also involved. In view of the frequency of 
multiple wounds, a complete examination had 
to be done so that secondary wounds would not 
be overlooked while concentrating on the tho- 
racic injury. 
General notes relating to diagnosis, — Con- 

I comitant injuries of the abdomen or neck 

I were sought for diligently. When abdominal 
rigidity was associated with a wound which 
was limited to the thorax, it was usually found 
only on the side of the injury, and was less 
marked on inspiration than when an intra- 
abdominal injury was present. The simple 
expedient of blocking the thoracic nerves, 
thereby enervating this portion of the abdomi- 
nal wall, was often of diagnostic aid. An 
abdomen that was silent on auscultation, or 
the persistence of spasm of the abdominal 
muscles after nerve block, indicated an intra- 
abdominal injury. Injury to structures in the 
neck was usually evident, but a careful exami- 
nation for emphysema of the mediastinum, 
neck, and chest wall, audible bruit, and signs 
of caval obstruction was essential. The import- 
ance of accurately plotting the tract of the 
missile cannot be overemphasized ; the evidence 
obtained was often the deciding factor for or 
against immediate surgical intervention. If the 
patient's condition permitted the taking of 
roentgenograms, upright posteroanterior, up- 
right lateral, and dorsal decubitus views of the 
chest, plus a flat plate of the abdomen, sufficed 
for the primary examination. 

Therapy in the initial or resitscitative phase. 
—The resuscitative triad included : (a) The res- 
toration of cardiorespiratory balance by the 
stabilization of the thoracic cage, elimination 
of pain in the chest by blocking the appropriate 
intercostal nerves, tracheal aspiration of the 


*'wet" lung, aspiration of blood when hemo- 
thorax was present, water-seal drainage of 
tension pneumothorax, and the administration 
of oxygen for anoxia; (b) replacement of 
fluids; and (c) early control of infection. 

The immediate correction of the cardio- 
respiratory imbalance was the most important 
single factor in aiding these patients. Although 
other resuscitative measures were often started 
simultaneously, the sealing of a sucking wound, 
permitting the return of the mediastinum to 
the midline by aspiration of pleural contents 
(air or fluid or both), the establishment of an 
unobstructed airway, and the relief of pain 
were the first considerations. The restoration 
of fluid balance was considered to be the sec- 
ond, and the prevention of infection, the third 
factor in early treatment. 

The extremely restless, apprehensive, and 
dyspneic patient was usually anoxic due to 
loss of blood (either external or into the pleural 
space), decreased vital capacity caused by com- 
pression of the lung by fluid or air, and atelec- 
tasis from blockage of the pulmonary radicles 
by excessive bronchopulmonary secretions. His 
efforts to rid himself of these burdens to normal 
breathing were further hindered by the intense 
pain that accompanied every voluntary effort. 
Therefore, his cough was feeble and ineffectual 
and the anoxia increased. 

Oxygen, 7 to 8 liters per minute, was admin- 
istered with a 12 to 18 F. nasal catherer 
attached to a portable oxygen tank. The appre- 
hensive patient tolerated a catheter much 
better than a mask. 

In our experience, aspiration of the trachea 
was best accomplished by use of a flexible 
woven catheter with a thumb suction release. 
The catheter was passed under the directing 
forefinger into the larynx. This was done with- 
out anesthesia and the maneuver was facili- 
tated if the patient's tongue could be pulled 
out with a gauze square. If an ordinary rubber 
catheter was used, it was best to clamp the 
tubing with a hemostat, preventing suction 
until the tip had been introduced into the 
trachea. While the initial aspiration brought 
relief by the removal of blood and mucus, 
repeated aspirations were also of value, espe- 
cially after nerve block when the uninhibited 



coLigh of the patient proved to be of great 


The pulmonary edema seen after blast and 

concLission injuries often persisted for a number 
of days. With subsidence of the shock syn- 
drome, bronchoscopic examination was made 
as frequently as twice a day, if needed- Oxygen 
delivered at the rate of 4 to 6 liters per minute 
under positive pressure by means of a close- 
fitting m^sk was valuable, but unless the tra- 
cheobronchial tree was free of secretions, the 
administration of oxygen was of little benefit. 

Regional nerve block, — ^This procedure was 
accomplished by the intradermal injection of 1 
percent procaine solution at the angle of the 
involved rib or ribs, including the two rib 
segments above and the two below the injury. 
Through these skin wheals, a 2-inch 20 to 22 
gage needle was introduced to the body of the 
rib. The lower edge of the rib was found 
and 5 to 8 cc. of 1 percent solution of procaine 
was injected. The relief of pain was immediate 
and amazing. The patient was able to cough 
more effectively and to aerate the lung more 
efficiently. Regional block was preferred to 
injection into the site of the open w^ound be- 
cause of the possible contamination. In non- 
penetrating fractures of the ribs, injection of 
the resultant hematoma gave some relief. 
Strapping of fractured ribs, as a means of 
affording relief from pain, was inferior to the 
blocking of the appropriate nerve or nerves, 
but was frequently used as an adjunct after 
blocking of the nerves had been accomplished. 

The me of morphine, — ^While this drug 
deserved its title of ''the doctor\s best friend 
and pain's worst enemy,'' it was found that 
it must be administered cautiously to patients 
with thoracic injury. The recently wounded 
patient, when admitted to a hospital, usually 
had already received one or two injections of 
morphine. This dose (the exact amount was 
determined, if possible) , coupled with the inade- 
quate circulation of shock, was apt to show a 
cumulative effect during resuscitation. Depres- 
sion of the cough and respiratory function, the 
actuation of which one was attempting to 
achieve, would then occur. 

''Stove-in'' chest and sternal fractures, — 
Treatment during the resuscitative phase was 

aimed at ''fixing" the collapsed chest wall in 
stable position. If the injury was unilateral 
this was best accomplished by wide adhesive 
strapping, beginning at the bottom and working 
up. The patient was directed to lie on the 
affected side and sand bags were used to main, 
tain this "fixed'' state. 

If the condition was bilateral, or if there 
was sternal separation or fracture, the chest 
wall w^as suspended by traction on towel clips 
attached to the costal cartilages or by traction 
through sternal screws. The position was main, 
tained with 2- to 4-pound traction over a pulley 
on an upright Balkan frame. If it was neces- 
sary to transport a patient under treatment 
with some foi-m of traction, the apparatus was 
incorporated in a plaster cast applied around 
the thorax from the level of the suprasternal 
notch to the lowest portion of the thoracic cage. 

Hemothorax (reduction i)i vital capacity),-^ 
The management of hemothorax, pneumotho- 
rax, or a combination of the two was the most 
common problem confronting the surgeon. It 
had been estimated that blood or air would be 
present in the pleural space in approximately 
70 percent of these patients. A hemothorax was 
not regarded as a simple hematoma but as a 
foreign body in a vital space. The pleural cavity 
responded to this irritation by *Sveeping" of 
serous fluid, resulting in additional increase of 
the pleural mass. 

The treatment was removal of the fluid and 
air. In the dyspneic patient with mediastinal 
shift, aspiration of the pleural contents was 
imperative. As much as 1,000 cc. of the con- 
tents could be removed safely at one time. 
When the patient complained of "tightness in 
the chest,'' it was wise to stop, as this symptom 
indicated that too rapid restoration of the nega- 
tive pressure had been accomplished. An orderly 
plan of regular aspirations w^as followed, begin- 
ning within the first 24 hours after injury and 
continuing daily until the pleural space was 
dry and the lung was completely re-expanded. 

Hemorrhage,— A question to be answered in 
the initial phase of treatment was, "has the 
bleeding stopped?'' If the injury was solely of 
the lung parenchyma, the compression of the 
lung by the fluid within the pleural space, the 
elevation of the diaphragm, and the low pr#- 



-lire within the pulmonary arteries combined 
\o lii^^^ hemorrhage. More than 1,500 cc. 

blood from parenchymal injury alone was 
^j^ysual, and secondary hemorrhage from 
parenchymal injury was very rare. Bleeding 
from hilar vessels was usually fatal, however, 
the patient usually dying before receiving hos- 
pital care. Bleeding from the mammary or 
intercostal vessels was usually progressive. 

Besides the roentgenologic changes and the 
physical signs of the reaccumulation of blood 
within the pleural space, the following criteria 
v\'ere used as a guide to diagnosing continuous 
hemorrhage: (a) A blood pressure that failed 
to rise after adequate transfusion of blood 
(up to 2,000 cc.) or which, having risen to 
normal levels, fell again. (6) Reaccumulation 
of 1,500 to 2,000 cc. of blood in the pleural 
space within 24 hours after the initial aspira- 
tion of a similar amount, (c) Persistent severe 
anemia in spite of replacement of blood ; degree 
of anemia determined by serial hematocrit 

When the diagnosis of persistent serious 
hemorrhage was made, surgical intervention to 
control the bleeding was indicated. During 
surgical intervention, there was an opportunity 
to remove all foreign material within the 
pleural space and to perform a decortication 
of the clot, which was adherent to both pleural 
surfaces, particularly the visceral surface. 

There was no evidence that early aspiration 
prolonged or brought about a recurrence of 
hemorrhage, nor was there evidence that air 
replacement was helpful. 

Sucking tvounds that had been occluded tem- 
porarily by sealed dressings or by approxima- 
tion of the edges of the wound were repaired 
with the same precautions as those observed 
in an intrapleural operation. Control of pulmo- 
nary pressure by intratracheal intubation was 
instituted, even though the procedure was done 
under local infiltration. With this safeguard 
to guarantee an adequate airway, care could 
be taken to debride all devitalized tissues. 

The wound of entrance of the missile was 
usually small and at times insignificant in 
appearance, but occasionally a huge jagged 
^'ound was present. The wound of exit was 
usually larger and more ragged. The tissues 

2r)8()15— 53 19 

between the two wounds were disrupted be- 
cause of the sudden release of the kinetic 
energy of the missile. The destruction of tissue 
depended directly on the velocity of the mis- 
sile at the moment of impact and the density 
of the tissue through which it passed. A missile 
could pass through parenchymal lung tissue 
with comparatively little damage, whereas the 
same missile traveling with the same velocity 
would produce extensive destruction when it 
struck a substance with greater density, such 
as a bone. In addition to the original missile, 
fragments of bone often acted as secondary 
missiles and produced additional damage. 

Traumatic wounds of the costal cartilage 
required surgical excision to prevent serious 
infection. If there was parenchymal damage 
within the chest that required extensive sur- 
gical treatment, the site of trauma was en- 
larged. It was found unwise to work at a dis- 
advantage, however, and frequently it was more 
expedient to complete the airtight closure of 
the sucking wound and do a secondary thora- 
cotomy and resection of a rib through a separate 
wound. Debridement and suture or resection 
of the damaged lung, removal of foreign bodies 
and splinters of bone, repair of the diaphragm, 
evacuation of blood and clots, and irrigation of 
the pleural space could then be accomplished 
with maximal efficiency. Injury to a pulmonary 
vein made it mandatory to remove the lobe or 
lobes that it drained. Extensive hematoma of 
a lobe was viewed with suspicion as to the 
future usefulness of that lobe. The lobe is 
vulnerable to infection and the possibility of 
traumatic arteriovenous fistula was recognized. 

The several points deserving attention were : 
(a) The surgical closure of a sucking wound 
must be airtight. (6) If the defect of the chest 
wall involved a large loss of bony structure, 
the insertion of a muscle flap to close this 
defect was done at the initial operation, (c) 
Because of its elasticity, parenchyma of the 
lung was closed by interrupted sutures rather 
than by a single continuous suture, (d) Positive 
pressure was used to determine adequate expan- 
sion of the lung before closing, (e) Closed 
water-trap drainage or suction with mild nega- 
tive pressure was instituted to aid in re-expan- 
sion of the underlying lung. • , 



Continued bleeding. — If bleeding was pro- 
gressive, thoracotomy was performed. The 
source of the hemorrhage might be the inter- 
costal vessels, the azygos vein, the internal 
mammary artery, hilar vessels, the diaphragm, 
the viscera immediately beneath, or extensive 
pulmonary lacerations. 

The management of sequelae of hemothorax, 
empyema or fibrinous pleuritis or both, was a 
major problem. Extensive tissLie damage plus 
bleeding combined to form fibrin clots. Thus 
the three immediate harmful eifects (a) blood 
loss, (b) pleural irritation, and (c) space oc- 
cupancy in the chest, were manifest. Some 
surgeons advocated early thoracotomy and 
evacuation of blood clots and fibrin. They be- 
lieved that the simple removal of the foreign 
substance would produce a cessation of the 
bleeding- by hastening re-expansion of the 
lung. The good results of repeated aspiration 
did not justify such radical surgical procedures 
in the acutely ill patient. Some surgeons prac- 
ticed irrigation of the pleural space through 
simple perforating wounds with an apparent 
reduction in the number of posttraumatic aspi- 

Injuries to the mammary and intercostal 
arteries were of two general types : (a) False 
aneurysms with subpleural hematoma and in- 
filtration, and delayed secondary hemorrhage, 
and (6) those associated with intrapleural 
laceration and continued intrapleural hemor- 
rhage. In the first type, isolation and ligation 
of the intercostal artery at points proximal and 
distal to the injury were necessary for control 
of the hemorrhage, as arterial pressure was 
exerted in both directions. If the bleeding was 
thought to be caused by injury to the internal 
mammary vessels, an anterior parasternal inci- 
sion was made at the desired level to expose 
these vessels. Disarticulation of the costocarti- 
lages was done if the primary exposure was 
inadequate. Open thoracotomy was necessary 
to correct bleeding from other sources. 

Thoracico-a hdo minal injuries, — In combined 
thoracico-abdominal wounds, the wound in the 
chest was explored first. Two fundamental rea- 
sons dictated this action. Intensive abdominal 
exploration was poorly tolerated by the patient 
with cardiorespiratory imbalance, and it was 

often possible to explore and repair the abdo * 
nal viscera through the diaphragm. 

Wounds of the superior surface of the liy^ 
were best repaired from the diaphragn^^y^ 
side. The application of free muscle or f^^ 
grafts, suture, or packing was often necessarv 
to control hemorrhage from the liver. Extensi^ 
laceration required abdominal exploration and 
diainage to avoid bile peritonitis. Fibrin foani 
was available in small quantities toward the 
end of the war and proved to be of great use. 

Lacerations of the spleen through a rent in 
the left hemidiaphragm were satisfactorily 
managed from the thoracic approach. Enlarge- 
ment of the diaphragmatic opening through its 
membranous portion and in a dii-eclion toward 
the esophageal hiatus furnished adequate 
exposure for inspection and repair of the stom- 
ach or for resection of the spleen. By palpa- 
tion through this opening, the entire abdominal 
cavity including the pelvis could be explored 
manually, but for obvious reasons this exami- 
nation might have proved to be inadequate. 
Because of the possibility of multiple injuries 
to hollow viscera by concussion or by direct 
trauma from high velocity missiles, a more 
complete visual examination through an ab- 
dominal incision was essential. 

The diaphragm was sutured edge to edge 
with interrupted silk sutures or slightly over- 
lapped. If there was a loss of substance of the 
diaphragm, the phrenic nerve was crushed 
where it courses over the pericardium, the pos- 
terior lateral attachment of the diaphragm was 
detached, the central defect of the diaphragm 
closed, and the posterior lateral edge of the 
diaphragm reattached to the intercostal muscles 
at a higher level. On the right side, if a large 
defect was present, a similar procedure was 
carried out, or else suture of the cut edges of 
the diaphragm to the capsule of the liver 
served as a temporary seal until the threat of 
infection was past. Then, if needed, a plastic 
repair with a fascial graft could be attempted. 

Hemothorax and infected hemothorax.-^ 
Prior to World War II, despite the teachings of 
some surgeons, the accepted therapy was indi- 
cated in the statement that "the mere presence 


a hemothorax warrants neither operation 
j]or aspiration/' This was soon regarded as un- 
tenable, because with the bloody effusion acting 
^5 a retained foreign body, a series of patho- 
logic changes occur. The fluid is pocketed by 
librin partitions, and organization of the fibrin 
deposits on the pleural surfaces begins. This 
laver of organizing fibrin binds down the lung 
and prevents re-expansion, so that the only 
manner in which the space originally occupied 
t)V effusion can be healed is by contracture 
of the chest wall, elevation of the diaphragm, 
and retraction of the mediastinum. These de- 
formities, which are the usual end result of 
untreated hemothorax, produce all grades of 
disability from slight to crippling limitations 
of the cardiorespiratory function. The early 
occurrence of fibroblasts in the investing layer 
of fibrin is the cardinal point in the pathologic 
changes that occur in hemothorax. The term 
"thickened pleura'' was a misnomer. The den- 
sity seen radiographically is the investing layer 
of clotted blood and fibrin, the serosal surface 
of which is loosely adherent to the pleura. 

Treatment by aspiration should start within 
24 hours. A delay of 5 or 6 days means increased 
difficulty in evacuating the cavity. Air replace- 
ment should not be used. The patient should be 
given a sedative, and adequate local infiltration 
should be made. If daily aspirations are needed, 
care should be taken to cause as little pain as 
possible, as the cooperation of the patient is 
necessary. Aspiration should be high in the 
chest. Some surgeons preferred aspiration in 
the ninth interspace in the posterior axillary 
line, the seventh interspace in the midaxillary 
line, or the fifth interspace if aspiration was 
done anteriorly. Others preferred the second 
or third interspace anteriorly. The rationale 
for the latter concept is that the diaphragm is 
frequently elevated in hemothorax and most of 
the fluid is in the upper parts. A large-bore 
needle (13 to 15 gage) was needed for some of 
the jellylike clots. Persistence and patience 
^vere the watchwords, for repeated aspirations 
^vere done until the pleural space was dry, until 
re-expansion of the lung was complete, or until 
it was not possible to remove fluid even with 
the large-bore needle. 

Decortication. — Until World War II decorti- 

cation never was widely used. It was indicated 
in patients in whom there was at least 30 per- 
cent persistent compression of the lung, in 
spite of repeated aspirations, especially if the 
apex was compressed, and in patients in whom 
primary aspiration had been unsuccessful. 

The optimal time for decortication was 3 to 
5 weeks after injury. If performed less than 2 
weeks after injury, the peel was thin and 
friable. The operation was tedious, as the poorly 
defined membrane had to be removed piecemeal 
or carefully wiped from the pleural surfaces. 
When performed 10 to 14 weeks after injury, 
the fibrous union between the peel and pleura 
was often so firm that a proper cleavage plane 
could not be established. The visceral pleura 
was frequently torn and the lung did not expand 
readily, because of fibrous ingrowths along the 

The operation was performed under intra- 
tracheal anesthesia through a thoracotomy 
wound. The parietal pleura and thickened peel 
were incised so that an opening was made into 
the ''hollow'' of the hemothorax. The liquified 
contents, clots, pus, and debris were evac- 
uated. The peel covering the visceral pleura 
was incised, and by careful dissection the cleav- 
age plane between these two structures was 
entered. Finding this line of cleavage was 
essential to the success of the operation. Two 
general methods were used: (a) The visceral 
peel was ''crosshatched'' and positive pressure 
applied to the lung by the anesthetist, thus 
expanding the crosshatched segments and caus- 
ing their edges to curl at their junction with the 
visceral pleura. The patches then could be 
dissected away bluntly, (b) A single incision 
down to the visceral pleura was made and by 
the use of gauze ''pushers" or dissectors, the 
peel was freed in one piece. 

Regardless of the method used to initiate the 
operation, the salient feature to be accomplished 
was the complete release of the incarcerated 
lung from the enveloping fibrinous membrane, 
in order that complete re-expansion could 
occur. Particular attention was directed to the 
costophrenic sulcus and the fissures of the lung, 
as fixation at these sites prevented total expan- 
sion. The most difficult portion to free was the 
apex of the upper lobe. The dissection was 



carried well down to the mediastinal hilar 


The visceral pleura beneath the peel was 
usually of normal consistency and was expan- 
sible when decortication was clone at the optimal 
time. Areas of atelectatic lung were gently 
teased by the surgeon's hand as positive pres- 
sure through the intratr^icheal tube was ^?radu- 
ally increased. Ballooning up of compressed 
lung to fill the thoracic cage completely so as 
to insure a satisfactory functional result was 
ample reward for exacting dissection. Unless 
unusual adherence of the peel to the visceral 
pleura had occurred, tearing of or bleeding 
from the pleural surfaces was minimal. Closed 
w^ater drainage with gentle negative pressure 
was instituted after decortication, 


Three hundi-ed and nine patients with 
wounds of the chest wall and lungs were ad- 
mitted to a hospital on the mainland. They 
w^ere received 2 months or more after the date 
of the injury. On admission they were grouped 
into three classes ; class 1 — those requiring only 
simple or no treatment upon arrival ; class 2 
(the largest number) — those requii'ing defini- 
tive treatment upon admission; and class 3 — 
those requiring elective treatment. 

The immediate first-aid treatment they had 
received was not always the same, and for the 
most part not ideal. Some had had excellent 
first-aid treatment, but owing to the distance 
between place of injury and a fleet or base 
hospital, and to the time required for the move 
to oiii mainland hospital, their clinical condition 
had been forgotten or overlooked along the 
way. Considerable credit, however, was due 
to the medical officers who first attended these 
men, for it was apparent that they had been 
handled competently. These medical officers 
were in no way responsible for the changes or 
complications that occurred in these patients 
as a result of their transfer from one medical 
activity to another. 

General consideraiions. — ^The types of tho- 
racic lesions requiring operation included hemo- 
thorax, hemopneumothorax, simple effusion, 
empyema, foreign bodies in the chest wall, lung, 
or mediastinum, bronchopleural fistulas, fibro- 

thorax, diaphragmatic hernia, ^rteriovenou 
aneurysm, injuries to the brachial plexus, sim ^ 
es of the chest wall, and pneumothorax. SoJ" 
of the patients had a combination of thoracic 
and abdominal injuries with orthopedic, skin 
and neurosurgical lesions. In a few instances 
hemothorax and even fracture of the ribs had 
been sustained after blast injury. All those 
men had received benefit from the use of sulfon, 
amides or from the combined use of sulfon. 
amides and penicillin. These two agents used 
in conjunction with therapy for shock were 
valuable prophylactic weapons that prevented 
complications and sequelae, and saved lives. 
The previous generous use of these agents may 
however, have misled medical officers who saw 
the patient for only a short time, the clinical 
condition appearing satisfactory in spite of the 
existence of a large hemothorax, sterile abscess, 
or even empyema, which remained unnoticed. 

Prelimirinrif e.ranii nations. — All the patients 
included in this study were examined roentgen- 
ographically and fluoroscopically after admis- 
sion. Because some weeks had elapsed since the 
date of injury, a few patients showed almost 
complete clearing of previously treated hemo- 
thorax, pneumothorax, or pneumonitis induced 
by ''concussion," and had practically normal- 
appearing chests with clear pulmonary fields. 
Many patients with class 1 lesions but with 
normal lung findings showed single or multiple 
fractures of the ribs, or the presence of metallic 
fragments. Very few instances of infection of 
the ribs were noted, perhaps due to administra- 
tion of sulfonamides and penicillin. 

Class 1 patients. — These patients required 
very little attention. Their treatment was al- 
most completed during the early phase, when 
treatment of shock, arrest of hemorrhage, cor- 
rection of disturbed cardiorespiratory function, 
and prevention of infection were inaugurated. 
Many patients were evacuated because of a 
small hemothorax or effusion, which cleared up 
en route. Some had been evacuated after suture 
of a **sucking*' wound or removal of a foreign 
body. A few had small effusions which appear- 
ed to be subsiding, and several had moist 
granulations that filled old chest-wall sinuses. 
These soon healed. Forty-nine had sustained 
through-and-through bullet or shell fragment 



ounds associated with hemothorax. On admis- 
4on, the pulmonary fields were practically 
^ornial and roentgenograms showed very little 

idence of the hemothorax recorded in their 
)iealth records. Several patients with abdomino- 
thoracic wounds involving the liver, diaphragm, 
;pleen, stomach, colon, or lung were operated 
aboard ship immediately after their injury 
gjid were no problem on arrival at our hospital. 

Class 2 patients, — In these, most of the prob- 
lems stemmed from the various sequelae of 
hemothorax. Practically all patients with 
\vounds of the chest, either penetrating or non- 
penetrating, had hemothorax of varying degree 
which collapsed and compressed the lung. In 
time the blood became clotted. In the interim an 
excellent culture medium for bacterial growth 
was afforded. Replacing air after aspiration 
was a poor practice and only invited complica- 
tions. The injected air maintained collapse of 
the apex, and when infection intervened the 
empyema was very large or even total, instead 
of small and limited to the base as it was when 
the upper lobe was allowed to re-expand and 
become adherent to the chest wall. Most wounds 
that penetrated the pleural cavity, even those 
causing parenchymal damage, resulted in pneu- 
mothorax; this set up the clotting mechanism 
even before the hemothorax became advanced. 
Therefore injected air only enhanced clotting. 

Of the 309 patients, 276 (89 percent) had 
hemothorax either upon evacuation or on ar- 
rival at our hospital. In all instances, patients 
with hemothorax were immediately submitted 
to aspiration, using a large (15 or 16 gage) 
needle. The procedure was repeated every 36 
hours or oftener. Aspiration alone without 
surgical intervention achieved a cure in 121, 
or 39 percent, of the patients; in several pa- 
tients aspiration was done only once. The 
smallest amount of fluid obtained was 30 cc. 
Penicillin was always instilled after aspiration. 
A large number of the 121 patients had re- 
peated thoracentesis because the pleural cavity 
^'as small. The clotted material interfered with 
aspiration only to a minor degree. While the 
finally dried-out pleura remained thick, the 
t^enefit gained by thoracotomy would not have 
been sufficient to warrant the surgical risk. In 
^any instances, the hemothorax was called 

''effusion'' because the fluid obtained appeared 
to have the typical straw color. A majority of 
these class 2 patients were returned to duty. In 
this group of 121 patients, the number who 
previously had not undergone aspiration and 
the number who had undergone aspiration prior 
to admission were about equal. Just why, in such 
a large number of instances, the hemothorax 
should clear up without the complications of 
clotting and serious infection cannot be ex- 
plained. At first we noticed that a few of the 
patients who had through-and-through bullet 
wounds had only a minor hemothorax. It was 
thought that the high speed of the bullet in 
passing through the body caused no injury to 
intercostal vessels and only minimal injury 
to the parenchyma of the lung. Later, patients 
with identical injuries came to us with almost 
total empyema, so this theory was abandoned. 

The same technique for aspiration and local 
anesthesia was used in every case. As a rule, 
a site in the midaxillary line was chosen with- 
out any attempt to place the needle in the 
most dependent interspace. When fluid was 
difficult to obtain, the use of a 2 cc. or 5 cc. 
syringe often brought success. Bacterial study 
of the specimen aspirated was made, and if it 
was found to be infected, examination for peni- 
cillin-resistant and penicillin-sensitive organ- 
isms completed the initial investigation. Much 
effort was necessary to rid the pleural cavity 
of fluid, debris, and clots. Sodium citrate, phys- 
iologic saline, azochloramid, and tyrothricin 
solutions were used for pleural lavage, depend- 
ing upon the nature of the aspirated material. 
In many instances, when the long-standing 
hemothorax was evacuated the lungs re-ex- 
panded. Even in patients with a small empyema, 
large amounts of penicillin were instilled after 
the lavage. Eighteen of sixty-eight instances 
of empyema were thus cleared up without sur- 
gical measures. 

The treatment of late or "old" thoracic inju- 
ries did not differ from that of recent hemo- 
thorax, because the treatment of choice was 
rapid re-expansion of the lung, which could be 
accomplished only by repeated aspiration with- 
out replacement of air. Early in the war, such a 
concept seemed to be rather dogmatic, because 
in prewar civilian practice treatment of hemo- 




thorax had been conservative in the hope that 
the blood v^ould be absorbed. 

Our statistics compare favorably with those 
of others in regard to results in patients \\ illi 
hemothorax, when considered from the stand- 
point of w^hether or not they had undergone 
aspiration previously. One writer found that 
17 percent of 200 patients who had undergone 
aspiration prior to admission to a base hospital 
had empyema, while 46 percent of 74 patients 
who had not had aspiration had empyema. Our 
figures showed that empyema developed in only 
13 percent of 200 cases in v^hich aspiration was 
carried out prior to admission, but in 54 per- 
cent of 80 cases in which aspiration had not 
been done previously. 

Chronic hemothorax avd decortication. — In 
the patients with chronic, clotted hemothorax 
only a small amount of prune- juice-colored 
fluid was obtained on aspiration, even though 
physical and roentgenologic examination of the 
chest indicated flatness and a massive opaque 
density. Many of these lesions were not in- 
fected, as determined by smear and culture. 
After repeated aspiration, the roentgenogram 
showed multilocular pockets and many fluid 
levels, A thoracotomy was performed, opening 
the pleural cavity very wide to remove the 
fibrin and fibrous pocketis that contained prune- 
juice-colored fluid and also yellow, custardlike 
clumps of old clotted blood. Nine patients 
required decortication because of a very tough, 
thick, fibrous layer deposited on the parietal and 
visceral pleurae that kept the lung compressed 
in a corsetlike vise. 

For decortication, the thorax was opened 
widely. A curvilinear incision like that for 
pulmonary resection was made, under intra- 
tracheal anesthesia. Fluid and the custardlike 
clotted material were scooped up and wiped 
out. Dissection of the organized, fibrous peel 
on the lung was then carried out. Closed suc- 
tion with a Stedman pump or underwater seal, 
if the area of decortication was small, was 
always employed postoperatively. 

Fluid and pus developed in four of these 
patients, bLit cleared up with aspiration and 
without further surgical treatment. One patient 
with sterile chronic, clotted hemothorax in 
whom decortication was done, had empyema in 

spite of closed, suction drainage, and further* 
surgical intervention was necessary. In thrg^ 
patients with infected, chronic hemothorax 
empyema occurred and rib resection was r^' 
quired. Two of the 4 patients in whom decorti,' 
cations were done 12 and 14 weeks after injury 
respectively had poor results ; when the thick 
peel was dissected much serum and blood oozed 
from the thin visceral pleura of the lung. The 
peel formed a tight union with the lung and 
fibrous adhesive bands extended through the 
visceral pleura and even into pulmonary tissue 
None of the patients with hemothorax reached 
our service less than 6 weeks after injury; 
most came after longer periods. Usually aspira- 
tion was tried first for about 2 weeks. This 
delayed the decortication operation for more 
than 8 weeks after injury — certainly not an 
ideal period. The dissections were very long and 
tedious and although we were enthusiastic in 
regard to a procedure which would eliminate a 
deforming thoracoplasty, the time that had 
elapsed since injury was a factor in determin- 
ing the relatively small number of decortica- 
tions that were performed. 

Empyema was the great problem in 68 of 
the 309 patients (22 percent) . In many of the 
patients in class 2, empyema occurred soon 
after injury. They had been variously treated 
prior to admission to our hospital ; some by 
closed intercostal drainage with a catheter, 
some by flap operations, and some by open 
thoractomy or by multiple thoracenteses with 
injection of penicillin. 

Hemothorax or thoracic injury often re- 
sulted in empyema no matter how ideal and 
diligent the treatment. In some instances empy- 
ema occurred because of poorly treated hemo- 
thorax, improperly timed open or closed drain- 
age, sucking wounds which sloughed after 
repair, persistent bronchopleural fistulas, or 
foreign-body reaction. Just as we were amazed 
to learn from the health records of some of the 
injured that a large hemothorax cleared up 
without ever being aspirated, we likewise had 
difTiculty in understanding why purulent fluid 
appeared a week or two after injury in some 
patients. What else besides bullets and shell 
fragments was carried into these injured chests 
can only be guessed. Chemotherapy and peui- 




eiiiin shared in reducing sequelae and mor- 
bidity. On the other hand, these agents gave a 
^^Ise clinical impression of improvement while 
gn unattended hemothorax v^^as turning into 
sterile pus and was in need of drainage. 

Classic methods of drainage were effectual 
in 29 patients with empyema, in none of whom 
did the residual cavity have a capacity of more 
^han 150 cc. All operations were performed in 
one stage. A long thoracotomy incision was 
made and segments of one to three ribs were 
removed. Convalescence lasted from 2 to 10 
weeks. There was no remaining thoracic de- 
formity in any of these patients. This was also 
true of the previously mentioned 18 patients 
with empyema, in whom the condition was 
cured by aspiration and instillation of peni- 

Twelve patients had thoracoplasty in stages, 
and 9 had one-stage procedures in which ribs 
and the thick pleural roof of the empyema 
cavity were removed and muscle transplants 
were used to fill in the defect. Of these 21 
patients, 12 had thoracic deformity. There 
was 1 lobectomy for lung abscess that followed 
pneumonitis and atelectasis complicating a 

Class 3 patients ( elective surgical treatment). 
—Class 3 patients included those for whom 
surgical treatment was elective. For the most 
part the operation consisted of removal of for- 
eign bodies in the chest wall or the pulmonary 
parenchyma. In addition, three foreign bodies 
were removed from the diaphragm and two 
from the mediastinum, three diaphragmatic 
hernias were repaired, and three arteriovenous 
or false aneurysms were treated. In class 3 
patients, surgical treatment was not under- 
taken prior to 2 to 4 months after the date of 
injury, in order that the patient might gain 
height and strength and that all possibilities 
of intrathoracic infection and pleural reaction 
^ight be eliminated. 

The only fatality in the 309 patients occurred 
in one with a false aneurysm. This man had 
l^een returned to duty overseas after sustaining 
^ through-and-through bullet wound of the 
right upper part of the thorax, which had 
Sealed quickly and without hemothorax. Some 
^'eeks later he was readmitted to the sick list 

because of hemoptysis. Upon the patient's ad- 
mission to our hospital, the roentgenogram 
revealed a shadow in the extreme apex of the 
right lung. During his preoperative period, he 
experienced an almost fatal hemoptysis. Trans- 
fusion of a large amount of blood permitted an 
operation, at which a large aneurysmal sac con- 
necting the subclavian artery with the apex of 
the right lung was found. The fibrous sac was 
being closed to be removed later, when the 
man died. 

Foreign bodies. — Removal of metallic for- 
eign bodies from the lung did not present much 
of a problem. For the surgical approach much 
the same technique as for pulmonary resection 
was used. Postoperative suction drainage was 
used, followed by early ambulation. 

Bullets and large shell fragments in the lung 
were removed after consideration of the size, 
proximity to important structures, and the 
likelihood of future inflammatory reaction. The 
minimal size for removal was set at 1 by 2 
cm. Many of the patients had metal fragments 
the size of a pinhead ; in others the size ranged 
up to 5 by 10 by 15 mm. Three patients had a 
salt-and-pepper effect, and, although the pos- 
sibility of pulmonary resection was considered 
because of the extremely large number of tiny 
fragments, they were discharged from the sick 
list without surgical intervention. 

Tissue response. — It was surprising to note 
the small amount of reaction around many of 
the retained foreign bodies, just a few months 
after the injury. The missile tracts usually 
healed early and the hemothorax and effusion 
cleared up. The patient's course was charac- 
terized by clinical improvement and progres- 
sive healing of the lesions, as determined by 
successive roentgenologic examinations. A 
metallic foreign body could, of course, carry 
clothing or other debris with it into the lung 
and be the source of future infection. One 2 
by 2.5 cm. shell fragment removed from the 
lung was well encased in fibrous tissue, but 
upon examination shreds of cloth on the metal 
were demonstrated. Another 1 by 1 cm, frag- 
ment shattered a lead pencil while passing 
through a pocket of the injured man. The frag- 
ment lodged in the lung and caused no reaction, 
although later suppuration of the tract and the 



discharge of bits of lead and wood occurred. 
The tract was excised but the fragment was 
not removed. Another fragment removed from 
an intercostal space contained a small amount 
of serous fluid in the fibrous capsule surround- 
ing the metal. In a patient with a large em- 
pyema that responded well to aspiration and 
treatment with penicillin, re-expansion of the 
lung caused movement of a foreign body, so 
that it ultimately sloughed through the visceral 
pleura and dropped into the small remaining 
empyema cavity, producing a large broncho- 
pleural fistula. Immediate rib resection was 
necessary and extensive surgical treatment was 
later required to eliminate the fistula. 

Localization technique. — Exact preoperative 
localization of large fragments was most im- 
portant. The method employed by our roent- 
genologist was simple and accurate. By fluor- 
oscopic examination, the position of the frag- 
ments was marked on the skin with a pencil. 
Metallic markers ^'A" and 'T^' were placed 
on the skin of the anterior and posterior chest 
walls near the fragment site and stereograms 
of the chest made. A true lateral roentgenogram 
of the chest also was made. The stereogram 
established the position of the foreign body in 
relation to the rib cage and the lateral view 
determined its position in relation to the an- 
terior and posterior chest walls. This technique 
was supplemented later, following a suggestion 
of several authors, by taking a roentgenogram 
in the lateral decubitus position, duplicating the 
position of the patient on the operating table. 

Postoperative regimen, — The usual postsur- 
gical procedures necessary for patients with 
thoracic injury were followed for the first 24 
to 36 hours, after which early ambulation was 
encouraged and exercises were started. Even 
patients too ill to be out of bed for weeks were 
given exercises supervised by the athletic in- 
structors of the physical education and rehabili- 
tation department and the technicians from 
the physiotherapy section. As soon as the man 
could sit up in bed and/or become ambulatory 
his exercises were increased to the point of 

A common finding in all patients with hemo- 
thorax or wounds of the thorax was atrophy of 
the pectoral and other muscles of the rib cage. 

In some, the atrophy was striking, the pati^ 
presenting a visible deformity on admission 
only a few weeks after injury. Exercise 
therefore an important part of the immediate 
treatment. The instructors and technicians 
stepped up the tempo of the physical activity 
as the clinical condition permitted, until such 
strenuous games as volleyball, basketball, and 
tennis became part of the treatment. 

Many a patient was admitted with a large 
hemothorax and one-half of his chest immobil. 
ized and apparently ''stove-in," only to become 
a robust man on the road to recovery after one 
or two thoracenteses and a regimen of exer- 
cises. The reason for this was just as obscure 
as that for the patient with total hemothorax 
that cleared without aspiration. 




Either major or minor wounds of the thorax, 
whether due to fragments, bullets, bayonets, 
or knives, have the potentiality of injury to 
one of the superficial or deep vascular struc- 
tures. It was difficult to estimate the incidence 
of this type of war injury, because most of these 
wounds were immediately fatal due to the im- 
possibility of tourniquet or pressure control. 
Some men so injured survived, however, and 
reached distant base hospitals for definitive 
treatment. The hemorrhage was at least tempo- 
rarily controlled by certain limiting anatomic 
structures and by the hematoma and infiltration 
of the surrounding muscles and tissues. The 
diagnosis was frequently missed because of the 
insignificance of the external wound or because 
of the lack of obvious extensive infiltration, 
hematoma, visible or palpable pulsation, or 
other significant physical finding. In many 
patients a diagnosis was not made until a 
serious secondary hemorrhage occurred. It be- 
came essential that every wound in this region 
be examined for evidence of arterial or vascular 
injury, especially by auscultation for the pres- 
ence of a bruit and by roentgenologic examina- 
tion for evidence of intrathoracic injury of 
vascular structures. 

Because of the serious nature of the opera- 
tion necessary to treat this type of injury, sur- 



jrical treatment was withheld long enough to 
ensure a reasonably certain diagnosis. It was 
essential to rule out functional bruits and those 
j-esulting from extrinsic infiltration or pres- 
sure on vascular structures. Operation was 
carried out as promptly as possible, however, 
in order to avoid secondary hemorrhage, pres- 
sure on adjacent structures, or a serious dis- 
turbance of the intrathoracic dynamics. 

Since no specific first-aid measures were 
effective in this type of injury, supportive 
measures were necessary to maintain the pa- 
tient long enough to reach hospital facilities 
equipped to carry out major thoracic surgical 
procedures. It was apparent, therefore, that 
these injuries required priority above all other 

Cardiac injury, — Penetrating wounds of the 
thorax with laceration of the heart often re- 
sulted in massive intrapericardial hemorrhage 
and associated tamponade. In a very small 
percentage of these cases, especially when there 
was only a laceration of the cardiac wall with- 
out actual penetration into the cardiac cham- 
bers, the intrapericardial hemorrhage did not 
produce an immediate lethal tamponade and the 
increasing intrapericardial pressure tended to 
control to some extent the hemorrhage from 
the cardiac musculature. Likewise, a small mis- 
sile passing into or through one of the cham- 
bers could, at least temporarily, produce a 
balanced tamponade without immediate com- 
plete cardiac embarrassment. Under these con- 
ditions, a small percentage of patients with 
this type of injury reached adequate operative 
facilities where the pericardium could be 
opened widely, the lacerations of the heart 
sutured and the pericardium drained. It was 
not feasible to do a temporary decompression 
of the pericardium in this type of injury, as it 
was in cases of tension hemothorax or pneumo- 
thorax. - - : - ' ■ ' - < 

Because patients with tension hemopericar- 
dium can survive only a very few hours at the 
most, the diagnosis had to be made at once and 
established by the clinical picture of cardiac 
tamponade. This was characterized by pro- 
found cardiovascular and respiratory disturb- 
ance, as evidenced by dyspnea, ashen cyanosis, 
and shock accompanied by an extremely weak. 

thready pulse, greatly lowered pulse pressure, 
increased venous pressure, and very distant 
muffled, weak cardiac sounds. These patients 
did not tolerate even a moderate degree of car- 
diac compression for long, and it was impera- 
tive that they be operated on through a left 
peristernal approach, the pericardium opened, 
and the hemorrhage from the cardiac wall or 
cardiac chamber controlled by carefully placed 
silk or cotton sutures. It was important to avoid 
the pleura, because pulmonary collapse often 
proved to be a very serious factor in an already 
critical cardiorespiratory balance. If the pleura 
was inadvertently opened, closed drainage, or 
preferably suction drainage of the pleural 
space, was imperative to facilitate as rapid re- 
expansion of the lung as possible. Likewise, the 
pericardium was always drained. In all of these 
injuries massive doses of penicillin were given 
intramuscularly. - . .,. , .... . . ■ ; : . ■ 

Intracardiac foreign bodies. — Intracardiac 
fragments lying free within a cardiac chamber, 
whether washed there via the blood stream 
after entering the vascular system at some 
distance from the heart, or introduced by direct 
penetration through the cardiac wall, were 
removed as soon as the condition of the patient 
permitted. Because there was usually severe 
shock, the added manipulation and loss of 
blood entailed in the removal of a fragment 
from a cardiac chamber was delayed until the 
patient had recovered from his initial loss of 
blood and cardiac tamponade. 

Blood was given by transfusion through at 
least two large-caliber needles to every patient 
with major cardiovascular injury undergoing 
any type of surgical treatment for relief of the 
injury. A purse-string suture was laid in the 
wall of the chamber and a circle of mattress 
sutures taken into the wall to control that par- 
ticular area during the probing for the frag- 
ment and the final closure of the opening. An 
incision was then quickly made through the 
wall in the center of these controlling sutures. 
A pair of heavy forceps was passed into the 
cardiac chamber, simultaneously tightening up 
on the purse-string suture and applying ten- 
sion to the surrounding mattress sutures to 
control to some extent the blood loss around the 
probing instrument. The fragment was located 


by a bimanual maneuver and removed. The 
cardiac wall was then sutured and the peri- 
cardium drained. As soon as the patient's con- 
dition permitted, it was also advisaljle to re- 
move fragments embedded in the pericardium, 
free in the pericardium, or in contact with the 
wall of a great vessel, because of the danger of 
erosion and serious secondary hemorrhage or 
the development of an aneurysm. 

Injury to mammary and intercostal vessels. — 
Although it was a well-established fact that in 
its early phases hemothorax should be handled 
by aspiration, it was necessary constantly to 
keep in mind that such an intrapleural hemor- 
rhage could come from a laceration of a mam- 
mary, intercostal, or hilar artery. In this case, 
early operation was required to prevent death. 

Injuries to the mammary and intercostal 
arteries were of two general types : (a) False 
aneurysms with subpleural hematoma and infil- 
tration and delayed external secondary hemor- 
rhage, and (6) injuries associated with intra- 
pleural laceration and continued intrapleural 
hemorrhage. The latter type produced symp- 
toms and signs of an increasing intrapleural 
pressure and mediastinal shift which prog- 
ressed until death ensued. Oxygen therapy and 
thoracentesis were useless unless the bleeding 
artery was ligated. This was in direct contrast 
to hemothorax resulting from injury to the 
lung, which was usually controlled by the pul- 
monary tamponade from the associated hemo- 

Physical signs of uncontrollable, progressive, 
intrapleural tension hemothorax demanded 
immediate exploration of the wound and a 
careful search for a lacerated mammary or 
intercostal artery. If this was found not to be 
the source of hemothorax, the thorax was 
opened wddely and the hilar structures exposed 
and inspected for a laceration of a major hilar 
pulmonary artery or vein. Such a vessel would 
necessarily require ligation irrespective of the 
possibility of subsequent pulmonary damage, 
although permanent pulmonary damage would 
be unlikely. Whenever a thorax was opened 
widely, it was necessary that it be drained by 
a closed method, suction preferred, in order 
to re-establish (luickly normal dynamics and 
re-expansion of the lung. 

Injury to vascular stnictures in the nied' 
tinum. — Injuries to the mediastinal vascnT* 
structures were quite common. In x^^^^ , 
stances, if death did not take place at oncefr^^^ 
massive hemorrhage, the hemorrhage was^^ 
least temporarily controlled by infiltration 
the surrounding tissues, with a resulting p^| 
sating hematoma or false aneurysm. 

Injury to subclavian vessels. — ^Injuries to the 
subclavian arteries were quite similar in many 
ways to injuries to other systemic arteries 
Being more deeply situated, the external infij* 
tration and hematoma were much less obvious 
however, and the diagnosis was made chiefly by 
the presence of a bruit and a widened medias- 
tinum as evidenced by the roentgenogram. 
(This was a rough bruit heard through systole, 
or during the entire cardiac cycle if an arterio- 
venous aneurysm was present.) 

It was a common finding to have not only a 
false aneurysm but also an arteriovenous aneu- 
rysm. This added complication of the arterial 
injury could often be diagnosed by an increased 
venous pressure in the arm involved and veno- 
grams showing a distortion or block of the 
vein at the level of the injury. 

Functional bruits were fairly common in this 
region and had to be distinguished carefully. 
This could be done by repeatedly examining the 
patient. The functional bruit vai'ied consider- 
ably from examination to examination and in 
relation to the position of the patient and the 
position of the upper extremity. Likewise, 
simple compression from external pressure and 
infiltration about the artery often produced a 
bruit. It was again essential to distinguish, if 
possible, between compression and true lacera- 
tion of a vessel with a false sac, for which 
surgical treatment was essential to effect a 
cure. If there was any question regarding the 
diagnosis of the type of bruit heard it was 
usually safe to keep the patient in bed under 
observation. As long as there were no signs 
or symptoms of further infiltration or cardiac 
damage, a careful period of observation could 
be carried out. The functional bruits could be 
ruled out by their inconstant nature ; the bruits 
due to pressure gradually decreased in intensity* 
as the roentgenologic signs of infiltration di- 
minished and the patient improved. 



Although false aneurysms and arteriovenous 
aneurysms of the subclavian artery were most 
hazardous surgical problems, the same general 
principles of management for all of the major 
vascular injuries were carried out. In order 
do this type of operation it was essential 
to have a fully equipped operating room, a 
trained anesthetist, adequate assistance, and 
continuous infusions during the procedure. It 
was found best to start the operation by tying 
large cannulas in the ankle veins of both legs so 
that if one cannula should become plugged at 
a crucial time in the operation the other could 
carry on satisfactorily ; if a very severe hemor- 
rhage was encountered, blood could be run 
through both as rapidly as possible. ^ . \ 

The general principle of approach to this 
type of injury was to avoid entering the false 
aneurysm at any point before the major artery 
and vein, both proximal and distal to the 
injury, and all significant branches of this sec- 
tion of the injured vessels were fully controlled. 
This was accomplished by accurate exposure of 
these vessels proximal and distal to the infil- 
trated site of the false aneurysm, and by control 
of the flow through these vessels by tension on 
small, soft catheters placed around them. The 
vessels were then further exposed until the 
false aneurysmal sac was finally entered and 
the actual injury to the artery visualized. Even 
with full control of the injured major artery 
and vein there was still a rapid flow of blood 
from the injured part into the sac. The ves- 
sels were then ligated, both distal and proximal 
to the injury, and the injured part was excised, 
carefully preserving for collateral circulation 
all branches that did not immediately enter 
into the tissue to be excised. 

In general, quadruple ligation and excision 
of the injured section of artery and vein was 
the procedure of choice from the standpoint 
of the greatest safety and curability. This 
radical management was usually necessary 
owing to the extensive damage to the vessels 
and surrounding tissues, making repair of anas- 
tomosis of the artery hazardous because of 
potential secondary hemorrhage or recurrence 
of the false aneurysm. In early cases and those 
in which reasonably normal tissues were en- 
countered, arterial reconstruction or exision and 

end-to-end anastomosis, if accomplished with- 
out undue tension, were, however, the best 
methods of management. 

To approach the subclavian vessels, a low 
cervical incision was made above the medial end 
of the clavicle. The lateral clavicular inser- 
tions of the sternocleidomastoid muscle were 
cut and the carotid sheath and its contents re- 
tracted medially. The scalenus anticus muscle 
was exposed, the phrenic nerve freed and 
retracted medially, and the muscle cut across. 
The subclavian artery was then exposed and a 
catheter passed around it for tourniquet action. 
Connecting with the original incision, a diag- 
onal incision was made across the pectoral 
region (similar to that for axillary exposure 
except that the pectoral muscles were split for 
the exposure of the axillary vessels immediately 
below the clavicle). The clavicle was then cut 
across and the ends retracted, widely exposing 
the injured part of the subclavian vessels. Dis- 
section of these vessels was carefully carried 
out in both directions until the neck of the sac 
and false aneurysm were isolated and entered. 
Here again, considerable bleeding was accepted 
as the final identification of the actual opening 
in the artery. The artery and vein were ligated 
proximal and distal to the laceration and the 
injured part excised. 

Because the brachial cords were closely asso- 
ciated with the aneurysmal sac, the missile had 
often done direct damage to these nerves. Fur- 
ther damage could be demonstrated from the 
pressure on and infiltration of the nerve trunks 
from the dissecting hematoma and false aneu- 
rysmal sac. It was necessary to isolate them 
carefully and produce no operative trauma, but 
no attempt was made to suture any of the 
cords that were found injured at this time. The 
clavicle was then wired together and the wound 
closed, with simple Penrose drains. 

Injury to the innominate artery, — False 
aneurysms and arteriovenous aneurysms in- 
volving the innominate, left subclavian, and 
left common carotid vessels within the superior 
mediastinum were diagnosed primarily on the 
basis of a bruit, roentgenologic findings of 
infiltration of the superior mediastinum, and 
induration extending into the suprasternal 
notch and the back of the neck. Submanubrial 



and cervical pain were the outstanding symp- 
toms. Again, because of the grave nature of 
the operation, it was absolutely necessary to 
be certain that this bruit was not due to some 
external infiltration and pressure on the artery. 
As long as the patient was kept in bed under 
close observation and there were no signs of 
cardiac hypertrophy or change, the surgical 
procedure could be delayed to establish beyond 
question of doubt the presence of a false aneu- 
rysm. Several patients were observed in whom 
the roentgenologic signs of mediastinal infil- 
tration and the bruit disappeared after weeks 
of observation. Continued pain, however, 
especially with exacerbations of pain, increasing 
or undiminished bruit, or any signs of cardiac 
effects, were considered a demand for surgical 
intervention. The same general approach was 
essential for this type of operation. Because 
of the close relationship of the vessels in the 
superior mediastinum and the base of the neck 
it was much more difficult to avoid entering 
the false aneurysmal sac before adequate ex- 
posure and complete control of the injured 
vessel were obtained. 

A transverse incision was made across the 
midpart of the neck above the clavicles and the 
suprasternal notch. This was then joined with 
a vertical incision over the midmanubrium. The 
suprasternal notch was exposed and the soft 
tissues retracted to expose the entire manu- 
brium and upper part of the sternum down to 
the level of the third interspace. The medias- 
tinal tissues were very carefully freed from the 
undersurface of the manubrium and a short 
section of the sternum down to the third inter- 
space. The mediastinal structures were pro- 
tected with a thin spatula and the manubrium 
split in the midline, carrying the division down- 
ward into the sternum to the level of the third 
interspace and laterally, connecting these inter- 
spaces on either side. The manubrium and 

sternum were then retracted widely by 
spreader retractor. This gave good exposuj.^ 
of the entire superior mediastinum and the arch 
of the aorta. The vessel involved was then 
isolated at its origin from the arch of the aorta 
and a catheter passed around it for tourniquet 
action. The vein was also isolated and con 
trolled in a similar way. Just beyond the bifuj 
cation of the innominate vessels the subclavian 
and common carotid arteries and their asso- 
ciated veins were isolated and likewise con- 
trolled with catheters. Finally, with full con- 
trol both proximally and distally by means of 
traction on the catheters or rubber-covered 
arterial clamps, the aneurysmal sac was 
isolated and the injured section of the artery 
excised after ligation both proximal and distal 
to the laceration. The manubrium was then 
wired together and the superior mediastinum 
drained with a simple Penrose drain. 

When these general principles were exercised, 
the mortality and complications were minimal, 
with only an occasional swelling and weakness 
of the upper extremity. No amputations were 
necessary and no treatment was required for 
any unusual circulatory disturbance in this 
respect. The extremity concerned should, how- 
ever, be carefully watched and kept exposed 
at room temperature, every effort being made 
to avoid constriction from clothing or position. 
Should significant circulatory disturbance de- 
velop, antispasmotic drugs and sympathetic 
blocks should be used. The patients recovered 
rapidly, but the function of the upper extremity 
was variable, depending on the degree of the 
original associated damage to the nerves and 
muscles. The lack of circulatory complication- 
was undoubtedly the result of the youth oi 
these patients, and probably this procedure 
could not be done in an older group of patients 
without serious circulatory complications. 

■ Chapter XVII - . ■ ,■ . . : . : 

Orthopedic Casualties Aboard a Hospital Ship 

Harold Lusskin, Commander (MC) USNR 

Some 70 percent of all combat casualties 
admitted suffered from one or more orthopedic 
injuries involving chiefly the back and extremi- 
ties. Large ragged wounds and compound com- 
minuted fractures were the rule. Sometimes 
hundreds of shell fragments were found within 
the wound, with bits of clothing and pieces of 
bone embedded in soft tissues elsewhere in the 

During the period when large numbers of 
casualties were being admitted, the task of 
the medical officers would have been an almost 
impossible one had it not been for the skill and 
cooperation of Hospital Corps personnel. They 
had received many hours of training in first 
aid and were therefore competent in arresting 
hemorrhage, treating shock, administering 
plasma, and applying splints, as well as thor- 
oughly indoctrinated in proper methods of 
transporting the injured. Above all, the corps- 
men were impressed with the importance of 
their part in treatment and took pride in a 
job well done. It is no exaggeration to state 
that their efforts frequently were determining 
factors in the ultimate result. 

To receive patients via gangways and cargo 
doors, or hoists, davits, and ladders was tedious 
and difficult. During hostilities, when as many 
as 700 casualties were waiting to be taken 
aboard, the delay, in spite of the utmost effort, 
was often appalling. The use of movable esca- 
lators, each large enough to hold an Army 
stretcher, would have greatly facilitated the 
reception of patients. With four escalators in 
service, fore, aft, starboard, and port, the 
ship could have been fully loaded within a 
comparatively few hours. 

In combat areas, large numbers of casualties 
had to be brought aboard as quickly as pos- 
sible. Often they came directly from the 
beaches, many of them in shock. Some had no 

dressings at all and others had not been dressed 
for days. Some were in casts, but others had 
free-swinging traction devices that aggravated 
pain. Many had Thomas splints with traction, 
which caused pressure across the dorsum of the 
foot and above the heel. As each casualty came 
aboard, he was examined by a medical officer 
who assigned him to a ward or operating room 
according to the severity of the injury. Corps- 
men administered plasma and tetanus toxoid 
or antitoxin, and when indicated applied tem- 
porary splints or pressure dressings. Morphine 
was given to relieve pain. 


Every operating room on the ship was ade- 
quately equipped to treat any orthopedic prob- 
lem. The rolling, pitching, and yawing of the 
ship limited the choice of therapeutic measures, 
however, excluding, for example, those requir- 
ing traction by free-swinging weights, which 
would swing with the ship's motion, aggravat- 
ing pain and sometimes displacing the frag- 
ments. Moreover, every patient had to be in a 
condition permitting immediate evacuation in 
case of fire or other emergency, and as most 
patients were transferred after 10 days, a fixed 
type of traction apparatus was used to permit 
their transfer from ship to ship or ship to 
shore. The limitations of space also precluded 
any form of prolonged traction as well as the 
time factor. The bunks were too close together, 
and there was little space between tiers or the 
fore and aft sections. 

In view of the large number of casualties 
taken aboard after every engagement, it was 
inadvisable to rely on external fixation methods 
such as the Roger-Anderson, Haines, or Stader 
splints, because the first boatload of wounded 
would exhaust the supply. Thus it was neces- 
sary to rely on techniques employing pins and 



plaster casts. Fractures of the humerus did 
well with casts and V/o or 2/0 pins; fractures 
of the tibia with casts and 2 pins ; femoral frac- 
tures with single spica and 1/2 pins. Fractures 
of the neck of the femur were not nailed aboard 
ship, but were immobilized in well-leg traction 
casts pending further treatment at a base hos- 


In the operating room, after careful inspec- 
tion, wounds were washed with soap and water, 
and easily accessible foreign bodies, such as 
bits of clothing or metal, were removed. In 
the debridement which followed, no attempt 
was made to reach every piece of metal, which 
would have been impossible in most instances. 
Foreign bodies in a joint, however, were always 

Fractures were brought into alignment fol- 
lowing debridement, using both the fluoroscope 
and roentgenograms as guides. Normal length 
of limb was maintained whenever possible, 
even in the presence of large bone defects. 

Since most combat wounds were extensive 
and the associated fractures comminuted, it 
was difficult to achieve immobilization with 
plaster casts alone, so pins incorporated in a 
cast were usually used. To permit dressings 
without disturbing the cast or limb, a large 
removable flap was cut in the plaster and then 
replaced to prevent the development of edema 
in the fenestrated area. If pressure was likely 
to develop, the cast was split to the skin. 

Once adequate immobilization was attained 
and the wound lightly packed with vaseline 
gauze, frequent dressing was unnecessary. 
Light packing with gauze was essential to 
prevent it acting as a plug and obstructing 
drainage. With this type of immobilization, the 
patient could be debarked from the vessel at 
a moment's notice, without need for special 
apparatus. Periodic roentgenograms showed 
the position of the fragments. Occasionally, 
when foreign bodies left in the tissues set up 
a reaction, they were removed through small 
incisions. Otherwise they were left alone. 


With the patient in traction on an ortho- 
pedic table, the wound was cleansed, debrided, 

and packed. Adequate traction usually 
rected lateral displacement, unless the pj.^^* 
imal fragment was very short. The distal fra^' 
ment was often flexed at the knee, but h 
suspending both fragments in slings, th 
could be lined up with the aid of the fluoroscope^ 
Slings and traction maintained the corrected 

A combination of full and half pins of the 
Steinman type was used, the full pins passing 
entirely through the bone, the half pins jus^ 
into or through the inner cortex. With the 
fracture reduced and temporarily immobilized 
it was then a simple matter to incorporate the 
pins in a plaster of paris spica extending from 
the lower ribs to the lower third of the leg. 

The site for the pins had to be chosen care- 
fully. Ideally the upper pin was placed just 
below the trochanters, penetrating the inner 
cortex of the femur but not extending through 
the bone. The lower pin was passed through 
the bone just above the condyles. In large 
wounds with extensive comminution, these 
optimum sites frequently had to be abandoned. 
Occasionally the upper pin had to be passed 
obliquely through the greater trochanter into 
the lesser, or the lower through the upper tibia. 

The thickness of the pins used was deter- 
mined by the size of the bone and the amount 
of traction necessary. The length was also 
important; the lower pins had to extend 2 
inches beyond the skin on either side of the 
leg — the upper, 3 to 4 inches on the side of 
insertion. If they were not long enough, they 
were likely to slip into the cast when the patient 
moved, for atrophy of the thigh was often 
rapid and severe. 

As soon as the cast was firmly set, traction 
was released and the foot and lower part of 
the leg included in the plaster. To prevent 
motion of the fragments, the cast was always 
extended from the toes to the mid-chest. When 
the slings were removed the holes in the cast 
were covered over. 

Once the half pin was in place, even a short 
upper fragment could be manipulated and 
brought into proper alignment without having 
to abduct the leg more than 20°. Immobilization 
was secure. The fragments could not slip and 
length was maintained. The patient could easily 



l^e turned within the confines of even the middle 
blink of a tier of three. If necessary, he could 
be evacuated on short notice, without need of 
elaborate equipment or loss of apparatus that 
could not readily be replaced. 

The fluoroscope proved invaluable in the 
i-eduction of fractures of the femur, obviating 
the need for subsequent trips to the operating 
room for the correction of malalignments. Be- 
cause of its frequent use, some protection had 
to be devised for patients and operator. Lt. 
Richard Hoffman improvised an effective ap- 
paratus for this purpose. Essentially it con- 
sisted of a portable fluoroscope with a long, 
narrow metal cone limiting the field and pre- 
venting scattering of the rays. An ordinary 
leaded apron, suspended between the patient's 
thighs, had a 5- by 6-inch window through 
which the cone of the fluoroscope was directed 
at the surgical field. With the aid of a head 
screen held just above or below the patient's 
sound leg, the roentgenologist could direct the 
surgeon in the exertion of traction or the 
manipulation of the slings supporting the 

Secondary atrophy of the thigh, which was 
frequent and severe, was compensated for by 
applying felt to the inner aspect of the leg or 
narrowing the plaster cast (without removing 
it). This last was done in one of several ways. 
Either a section of the cast was cut away on 
the inner side of the thigh, above the lower pin, 
and replaced with fresh plaster closer to the 
skin, or wedges were cut in front and back and 
the spica narrowed at those points, or the 
entire front of the cast was removed and re- 

During the summer of 1944, about 45 
patients were treated by these methods with 
gratifying results. Even when further measures 
were required after evacuation to a base hos- 
pital, the procedure as performed conserved 
time, position, and length of limb. 


To understand the special problems pre- 
sented by the intertrochanteric type of frac- 
ture, it is necessary to consider the mechanics 
of the hip. The glutei, tensor fasciae latae, 
adductors, rectus femoris, long head of the 

biceps, and inner hamstring muscles exert a 
steady pull on the shaft of the femur, mainly 
in their own direction. Since the neck of the 
femur forms an angle of 135° with the shaft, it 
is subject to a constant shearing force. The 
intertrochanteric area, which is almost at right 
angles to the neck, is not parallel to the shaft 
of the femur but inclined toward its long axis. 
Thus a fracture at this point does not cause 
the shaft to slip past the neck, as in intra- 
capsular fracture, but rather, the upward 
thrust is transferred to the lower end of the 
neck, the proximal fragment is pushed upward 
at the site of the fracture, and coxa vara 
occurs. Numerous methods have been tried 
to counteract this tendency, with varying de- 
grees of success. 

The ordinary plaster of paris spica is inef- 
fective. As it rides up on the body, it carries 
the femur with it, causing a recurrence of the 
deformity. The double spica also overrides an 
inch or two, after atrophy takes place or if 
much padding is used. Sometimes good results 
are obtained by the application of a plaster of 
paris spica with the limb in extreme abduction, 
so as to cause the greater trochanter to impinge 
upon the ilium, maintaining an angle of 135° 
between neck and shaft. The trochanteric im- 
pingement on the ilium prevents the shaft from 
riding up. The position is awkward and pain- 
ful, however, and transportation is difficult. In 
addition, the Navy bunk is too narrow to con- 
tain the abducted limb. 

Similar considerations countraindicated sev- 
eral other procedures in common and success- 
ful use in hospitals, notably Russell skin trac- 
tion and skeletal traction through pin or wire. 
With these techniques a regular hospital bed 
is needed, to which a special Balkan frame or 
its equivalent can be attached. Also, the traction 
apparatus must be detached for transportation 
of the patient, and Thomas splints must then 
be applied. Pain and loss of position results. 

Transfixion by the Smith-Peterson nail, mul- 
tiple pins, or wires is not feasible in the tro- 
chanter because the area does not afford suf- 
ficient space for a good bony purchase. The 
meager grip obtainable is easily vitiated by 
the muscular pull on the limb, and coxa vara 
recurs. A combination of nail and plate effec- 



tively overcomes this weakness, but is not 
applicable to the compound and comminuted 
fractures that are the rule in combat casualties. 

With well-leg traction using the Roger-An- 
derson apparatus, it is possible to maintain a 
constant pull on the injured limb, as in Russel 
and skeletal traction, and transportation pre- 
sents no difficulties. Moreover, no special bed 
is required and the method is effective in 
simple, comminuted, or compound fractures. 
By utilizing the sound leg both as a fulcrum 
and a site for the application of countertrac- 
tion, the injured limb can be held in proper 
position at all times. The drawback to this pro- 
cedure is that the apparatus leaves with the 
patient on transfer and the supply of this 
equipment is soon depleted. 

It was necessary to devise a procedure that 
would secure the advantages of the techniques 
cited without their drawbacks. A combination 
of three methods — well-leg traction, skeletal 
traction, and the double spica plaster of paris 

cast solved the problem. With the patient on 

an orthopedic table, a Steinman pin was passed 
through each femur just above the condyles. 
Traction was applied to the injured limb, and 
pressure to the well leg, until the coxa vara 

was corrected. A double plaster of paris 


was then applied from just above the \\[ 
crests to the toes, with the pins incorporate^ 
in the cast. Also incorporated were reinforcin 
crossed bars, to prevent the limbs of the cast 
from breaking and disrupting the traction 
maintained through the pins. 

In fractures involving both legs, each ex- 
tremity was pinned individually and individual- 
ly encased in plaster. It was then possible to 
apply well-leg traction when necessary, because 
the pins, fixed in the plaster, prevented dis. 
turbance of the fragments on either traction 
or compression. ^ 


An experience with about 80 wounded Japa- 
nese prisoners forcibly demonstrated the value 
of immunization against tetanus and early ad- 
ministration of antitoxin. Within a week after 
their admission to the ship, about 25 percent 
of the prisoners had tetanus in spite of the 
antitoxin administered when they came aboard. 
Heroic measures failed to save them for they 
apparently had not been immunized prior to 
injury. In happy contrast, not one of the 
thousands of our casualties developed tetanus. 

Chapter XVIII 


Albert Salisbury Hyman, Captain (MC) USNR 

During the years 1942 through 1945, there 
^^ere more deaths among Navy and Marine 
Corps personnel from cardiovascular diseases 
than from any other cause except trauma. In 
a war of unprecedented violence, 4,477,886 sick 
days were lost because of simple fractures, a 
very common injury, while 3,411,722 sick days 
were lost because of heart disease. 

The Medical Statistics Division of the 
Bureau of Medicine and Surgery reported in 
1945 that out of 5,346 medical deaths, as com- 
pared with 22,197 surgical deaths in a similar 
period, about one-seventh of the deaths from 
medical conditions were due to heart disease. 
Of these, 797 patients died from coronary artery 
disease and thrombosis, and 53 died from 
various forms of rheumatic heart involvement. 
The sick days lost by the former group totaled 
only 213,232, while 3,198,490 sick days were 
lost by personnel with acute rheumatic fever 
and its cardiac complications. Further, of 11,- 
734 men in whom a diagnosis of heart disease 
was made, 6,928, or about 59 percent, were 
invalided from the service. Mitral valvular 
insufliciency was noted in 3,961 patients, mitral 
stenosis in 1,584, coronary heart disease in 
1,372, chronic myocarditis in 1,194, and acute 
dilation of the heart in 116. Only 667 patients 
were found to have hypertensive heart disease, 
although many hundreds were noted to have 
high blood pressure. 

In spite of the apparent high incidence of 
cardiovascular disease in the Navy during 
World War II, the rate was no greater than 
that occurring in comparable groups in the 
general population. No other medical disability 
presented greater problems in preventive medi- 
cine. In the younger age group rheumatic fever 
accounted for a huge toll of sick days; in the 
older age group, coronary artery disease killed 
fibout 200 officers and enlisted men. 

238015— /i3 20 


The objective signs and symptoms of heart 
disease were usually not difficult to evaluate, 
but early or potential cardiovascular disability 
presented a most difficult diagnostic problem. 

In the list of causes for rejection for enlist- 
ment, diseases of the heart and blood vessels 
ranked third. During 1942, about 15 percent of 
Selective Service candidates were disqualified 
because of organic heart disease, but during 
1943 only about 7 percent were found to have 
disqualifying heart disorders. It was the older 
group of personnel that was primarily respon- 
sible for the high incidence of heart disease in 
the services. 

Diagnostic cardiac clinics were established in 
the various naval districts to cope with enlist- 
ees and inductees who presented borderline 
findings. The first Cardiac Consultation Service 
was set up at the U.S. Naval Hospital, Brook- 
lyn, N. Y., on 15 December 1941. To this clinic 
were referred all men with doubtful cardio- 
vascular conditions discovered at recruiting 
offices within the Third Naval District. Later, 
similar diagnostic clinics were established in 
Philadelphia, Boston, Baltimore, San Francisco, 
and other large cities. 

It was soon recognized by all examining phy- 
sicians that criteria for the identication of early 
or potential heart disease required codification. 
The Committee on Cardiac Examinations dis- 
seminated factual information relating to this 
problem in diagnosis. The number of ^'missed'' 
cardiac cases in a sample survey taken in the 
New York area showed a drop of nearly 60 
percent within 3 months after the introduction 
of these diagnostic criteria. 

The f unctional systolic murnfiitr. — The largest 
number of doubtful cardiac conditions referred 
for special examination were in men who had 



systolic murmurs. Using the modification of the 
point scoring system suggested by Hyman, a 
systolic murmur, especially when localized at 
the apex, was considered as functional regard- 
less of the loudness or pitch of the murmur 
when no other cardiac abnormalities were 
noted. Phonocardiographic studies made at the 
U. S. Naval Hospital, Brooklyn, showed that 
both functional and organic systolic murmurs 
had the same graphic pattern and the sounds 
were identical in both types of murmurs. 

A history of two or more attacks of rheu- 
matic fever during childhood or adolescence and 
the presence of a systolic murmur was sufficient 
evidence to disqualify the applicant for enlist- 
ment. Various combinations of cardiac abnor- 
malities were noted; the most common was 
slight enlargement of the heart and a poor 
exercise tolerance test. Another combination 
was a slight delay in the P-R interval to 0.24 
second, associated with enlargement of the 
heart, lowered vital capacity, and a poor pulse 
rate response. In the presence of systolic mur- 
murs, all of these men were considered to have 
mitral valvular disease. 

Correlation unit scoring studies were made 
on 1,986 men referred for cardiac investiga- 
tion; of these, 1,144 or 57 percent had systolic 
murmurs. After evaluation 421, or about one- 
third of those with murmurs, were finally con- 
sidered to have organic heart disease. 

Paroxysmal hypertension, — Systolic blood 
pressure levels of 140 to 160 mm. Hg or higher 
in young men, constituted the second largest 
group referred for consultation. In most of 
these patients this finding was caused by psy- 
chosomatic factors — nervousness and an un- 
stable vasomotor mechanism. After a resting 
period, the blood pressure often returned to 
normal limits, although some were required to 
reappear on several successive days before 
acceptable levels were obtained. Of 46 young 
men with initial systolic readings above 140 
mm., 17 were found to have normal blood pres- 
sure on the second examination, 12 on the 
third, 8 on the fourth, and 6 on the fifth exami- 
nation. Tw^o had evidence of renal disease, and 
one had essential hypertension. 

No applicant was accepted until one reading 
below 140 mm. was obtained. This was in con- 

trast to the recommendation of the New- 

Medical Advisory Draft Board that 



with pressures as high as 170 mm. were accept 
able for service, provided the diastolic ley^i 
was below 95 mm. There was evidence to indj 
cate that the so-called tendency to high bloo^ 
pressure in young persons may be followed later 
by permanent hypertension. After World War 
I, Brooks, Friedman, Libman, and others inves. 
tigated a number of juvenile hypertensive pa. 
tients over a period of several years, most of 
whom eventually succumbed to a variety of con. 
ditions secondary to high blood pressure. 

Labile blood pressure levels were considered 
to be nondisqualifying provided one normal 
reading was obtained. This decision of the 
Committee was frankly a compromise between 
the military demands of the time and the avail- 
able medical opinion concerning paroxysmal 

High diastolic blood pressure alone was an 
infrequent finding. Out of 21 men with a dias- 
tolic pressure over 100 mm., 16 had evidence 
of associated kidney involvement. Only in rare 
instances was the diastolic blood pressure ele- 
vated in the psychosomatic group, and it was 
largely upon this dissociation of the systolic and 
diastolic levels that a diagnosis of juvenile or 
paroxysmal hypertension was made. When both 
levels were elevated, the applicant was consid- 
ered unacceptable. In the New York area the up- 
per normal qualifying levels were systolic 140 
mm. and diastolic 94 mm. These figures w^ere 
higher than the acceptable normals in other 
parts of the nation; in the Southern States, 
for example, 132/80 was considered to be the 
upper limit of normal. This was in keeping with 
life insurance surveys which indicated that 
blood pressure levels were generally higher in 
urban than in rural areas. 

Functional cardiac irregularities. — Prema- 
ture contractions or extrasystoles were found 
in 64 percent of the men referred for cardiac 
study. The diagnosis was ordinarily made with- 
out verification by electrocardiogram. The ec- 
topic focus responsible for the premature beat 
was in the ventricles in about 82 percent of the 
patients. Auricular extrasystoles occurred in ^ 
percent, nodal premature contractions ^vere 
seen in 4 percent, and extrasystoles from two 



more ectopic foci were noted in 6 percent. 

xvanclering pacemaker was a rare finding. 

In the absence of any other evidence of heart 
jisease, estrasystoles per se were not considered 
^0 be disqualifying. No attempt was made to 
classify the ectopic contractions into the effec- 
^jye or ineffective types; after a brief period 
qI observation the Wolffe-Digilio index was 

Simple sinus tachycardia with rates as high 
160 was discovered in many applicants. 
Unless the condition was associated with signs 
of thyroid dysfunction or other evidence of 
cardiac disability the candidate was not dis- 
qualified. Most young men with rapid pulse 
rates also showed the syndrome formerly 
called neurocirculatory asthenia, and in the 
light of psychosomatic medicine, these patients 
could now be classified under the various groups 
of anxiety neuroses. Usually there was a recur- 
rence after exposure to any hostile environ- 
ment. Further large scale study of these persons 
is important in a final determination of their 
eligibility for future military duty, experience 
in the combat areas having shown most of them 
to be unreliable manpower. 

In certain instances the change in the pulse 
rate was so abrupt or so irregular that a diag- 
nosis of premature contractions was considered. 
In 3 cases, auricular fibrillation was mistaken 
for sinus arrhythmia. 

A group of 84 applicants were referred for 
irregularities which were subsequently demon- 
strated to be exaggerated types of sinus ar- 
rhythmia, and in many of these an electrocar- 
diogram was necessary to establish the diag- 
nosis. Regardless of the degree of irregularity, 
however, the condition was not considered by 
the Committee to be disqualifying. 

Paroxysmal tachycardia was discovered in 
11 applicants and a presumptive history of one 
or more attacks was obtained from 9 others. 
In the absence of any other cardiac abnormality 
and with a negative history of rheumatic fever, 
the candidate with only one episode was 
accepted for enlistment. Where there was a 
history of two or more episodes, however, the 
condition was considered to be disqualifying. 
Subsequent follow-up of four of these young 
^en disclosed that each of the four had a 

number of episodes in the succeeding years. In 
seven other men, rheumatic heart disease was 
discovered, while three applicants had evidence 
of essential hypertension. 

Paroxysmal tachycardia in the older age 
groups (40 to 55) was considered to be serious. 
It is doubtful whether men in this age group 
with a history of previous attacks of paroxys- 
mal tachycardia should be accepted for service, 
even if there is no other evidence of cardio- 
vascular disability. 

Paroxysmal auricular flutter and fibrillation 
were seen occasionally. In young men who had 
no demonstrable heart disease, the occurrence 
of a single attack was not considered to be 
disqualifying, but where there was a history 
of two or more episodes the applicant was 
rejected. In men beyond the age of 30, how- 
ever, the condition carried a more guarded 
prognosis and was considered to be disqualify- 
ing. A follow-up of two men for about 3 years 
showed that neither had recurrence, although 
both saw sea duty. This tends to confirm the 
opinion of authors who believe that paroxysmal 
fibrillation may occur in an otherwise normal 
heart. Some consider the syndrome psychoso- 
matic in origin. 


Probably a million electrocardiographic trac- 
ings were taken during the war years, most of 
them on normal persons. Nearly all electro- 
cardiographic studies made in civil life prior 
to World War II were carried out on patients 
with heart disease. Normal series were usually 
secured from medical students, school children, 
and insurance applicants, from which small 
group of controls, the so-called normal stand- 
ards, were developed. As the number of trac- 
ings began to accumulate, many observers noted 
that the previously accepted standards had been 
too limited. Wide variations in the electrody- 
namic cycle were discovered in healthy athletic 
young men and correlation studies revealed no 
cardiac abnormalities. In nearly all, there was 
no history of rheumatic infection or previous 
cardiac disability. Under the conventional elec- 
trocardiographic standards defining what were 
then considered to be the limits of normal these 



young men would have been disqualified for 
service in the Armed Forces. 

Prolongation of the P-R intervaL — Most 
authorities accepted 0.20 second as the upper 
physiologic limit of this period. There were, 
however, a large number of candidates with 
much longer P-R intervals, some as high as 
0.26 second. More common was the group with 
0.22 second. In the absence of a history of 
rheumatic fever and with no objective evidence 
of heart disease, they were considered qualified 
for enlistment or commissions. A few men with 
P-R interval of 0.24 second were also accepted. 

While a fixed or permanent delay in conduc- 
tion to 0.26 second may be "normal" for a 
given individual, a changing P-R interval was 
regarded with suspicion. For example, in one 
applicant, age 21, the electrocardiographic 
tracing showed a P-R interval of 0.24 second : 
an ECG made 10 days later disclosed an in- 
crease to 0.28 second. He had no physical or 
laboratory signs of rheumatic fever and gave 
no history of having had the disease. In a 
third tracing about 2 weeks later, the P-R 
interval had returned to 0.22 second and a 
faint systolic murmur over the mitral area was 
then heard for the first time. He was rejected 
with a diagnosis of subacute rheumatic heart 

When time permitted, all applicants in whom 
the P-R interval was found to exceed 0.22 
.second were observed for several weeks, trac- 
ings being taken every 10 days. If there was no 
demonstrable change during the period of ob- 
servation, they were accepted for enlistment. 

Left axis deviation. — In boys and young men, 
left axis deviation was ordinarily considered to 
be evidence of cardiac involvement, in the 
absence of a mediastinal shift secondary to 
pulmonary disease or other lesion of the chest. 
The condition was frequently associated with 
left ventricular hypertrophy and was seen in 
patients with relatively long-standing aortic 
or mitral valvular disease. Less common were 
the various types of idiopathic hypertrophy of 
the heart. In certain persons with wide thoracic 
measurements and narrow pelvic brims (hyper- 
sthenic classification of Draper) the anatomic 
axis of the heart may be greater than 45°. This 
may be sufficient to shift the electrodynamic 

axis toward the left during shallow breathin 
When, however, the diaphragm is dropped dur 

ing deep inspiration, the heart becomes hiqj.* 
vertical and the original left axis deviation ma 
In all cases where left axis deviation was di^ 
covered in men under 25, the third lead 
repeated during deep inspiration. Appiicaj^^. 
were accepted if the left axis deviation disap 
peared. If the deviation was only slightly 
duced or unchanged, the condition was con. 
sidered to have clinical significance. 

QRS delay. — The upper limit of norma] for 
the duration of the QRS complex was generally 
agreed to be 0.10 second. Many otherwise ac- 
ceptable applicants showed a delay in conduc- 
tion time to 0.12 second, and a few values were 
as high as 0.16 second. The problems previously 
considered in the prolonged P-R period were 
equally applicable to the lengthened QRS com- 
plex. A QRS of 0.12 second, if constant, was 
considered as normal. Under certain circum- 
stances, even 0.14 or 0.16 second was acceptable, 
but an increasing QRS was considered to be 
suggestive of rheumatic infection. 

Q-waves. — In the older age groups (35 to 
55), the discovery of Q- waves, particularly in 
leads I and II and in chest leads CF_,, CF.-,, and 
CFo, offered a challenging diagnostic problem. 
In many men a ''small" Q-wave was accepted 
as normal, although most authorities agreed 
that such Q-waves should not exceed 0.2 mv. 
Many applicants in this age group showed 
Q-waves as deep as 0.6 mv., and where a his- 
tory of coronary insufficiency or anginal pain 
was secured, such deep Q-waves were regarded 
as diagnostically significant and the applicant 
was ordinarily rejected. In the absence of a 
history of stenocardia and with no objective 
findings of coronary artery disease, Q-waves of 
0.4 mv. were not considered to be disqualifying. 

ST segmental changes, — A surprisingly large 
number of young men were found with ST S^Sg- 
ments elevated above the isoelectric line, in 
some instances as high as 0.6 mv. Repeated 
examinations over a period of months showed 
no change in a selected series of 44 cases, and 
where there was no evidence of rheumatic 
heart disease, this finding per se was not con- 
sidered to be disqualifying. In the older age 



^oups, however, a depression of the ST seg- 
jjient below the isoelectric line was considered 
be more important than a deep Q-wave in 
the presumptive diagnosis of coronary insuf- 
liciency or disease. After careful examination 
gnd repeated exercise tolerance tests, most of 
these men were found physically unfit for mili- 
tary service. 

T^ivaves, — Most authorities believe that in 
leads I and II, the T-waves should normally be 
upright and of relatively high voltage. Iso- 
electric and negative T-waves in the older 
group were usually associated with serious 
myocardial and coronary changes, while in the 
younger group, rheumatic infection was the 
most common cause of the abnormality. Many 
men in their 50's may have a low Ti without 
necessarily showing signs of coronary disease, 
and evaluation of the degree of lessened voltage 
that should be considered significant in any 
given case may depend on careful study and the 
application of knowledge gained only from 
personal experience. In general, Ti should have 
an amplitude of at least 0.1 mv. Men with 
isoelectric or inverted Ti and/or To were not 
accepted for enlistment. 

T-waves in the chest leads, — In most adults 
the T-waves are upright in leads CF4, CF5, 
and CFg, while in children, some or all may 
be inverted. Some young men may retain the 
inverted CF4 T-wave pattern, but when it is 
discovered after the age of 25 it should be re- 
garded with suspicion. A number of deaths 
from coronary artery disease were reported 
in servicemen under the age of 30, some of 
whom were known to have had negative CF4 
T-waves prior to enlistment. 

Q-T interval — While the Q-T interval is of 
much less importance than either the P-R or 
QRS, lengthening of the interval may have 
some clinical significance. The generally 
accepted upper limit is 0.40 second or twice 
the P-R in any given case. In younger persons 
it may be prolonged as the result of rheumatic 
disease. In the older groups, it may represent 
an old coronary episode and may remain long 
after the T-waves have returned to normal. 
I^elay in the Q-T interval beyond 0.44 second 
is ordinarily seen only in association with other 
signs of cardiac involvement. 

Multiple abnormalities, — In considering the 
electrocardiogram as a whole, any one of the 
abnormalities previously noted might, in cer- 
tain instances, be accepted as normal for a given 
individual. When there were two or more such 
changes present, however, the condition was 
regarded as evidence of cardiac involvement. 
As an example, one applicant for the Air Corps 
showing a P-R of 0.22 second, a QRS of 0.12 
second, and STi elevated to 0.4 mv. and a Q-T 
of 0.42 second was considered to be disqualified 
because of presumptive rheumatic heart disease, 
although he had no murmurs and denied rheu- 
matic episodes. He succeeded in joining another 
service, however, and 4 months later was hos- 
pitalized with valvular heart disease. 

The same rule held for the older age groups. 
A 46-year-old officer was found to have per- 
sistent left axis deviation, a QRS of 0.12 second, 
a slightly depressed STi, and a Q-T of 0.44 
second. Physical examination was otherwise 
negative and he denied symptoms of any kind. 
While on sea duty about 3 weeks later, he had 
a myocardial infarction requiring transfer to 
a hospital. 


No cardiovascular examination was consid- 
ered adequate without roentgen visualization 
of the heart and aorta. As with the hitljerto 
accepted standards employed in electrocardiog- 
raphy, studies of a large number of roentgen- 
ograms of normal young men made possible 
the accumulation of new statistical data not 
previously available. Most military medical 
boards considered that these new data proved 
that the previous upper limits of heart size, 
as set forth in the Hodges-Eyster tables, were 
too small. The Selective Service Medical Board, 
for example, permitted 1 cm. to be added to 
all cardiac and aortic measurements. 

Simple left ventricular enlargement, — Many 
well-built and vigorous young men were found 
to have prominent left ventricular borders of 
the heart. Investigation of this problem indi- 
cated that simple enlargement of the left ven- 
tricle alone was a benign process, and appli- 
cants presenting a prominent left cardiac border 



v^ere accepted. When the entire heart was 
enlarged, however, and measurements were 
more than 10 percent above the Hodges-Eyster 
tables, the applicant was disqualified. Of con- 
siderable interest was the discovery in young 
Negro men of left ventricular enlargement, in 
many instances a part of the syndrome of sickle 
cell anemia. 

Prominent conus arteriosus. — A definite in- 
crease in the shadow of the conus arteriosus is 
ordinarily associated with mitral valvular dis- 
ease or lung lesions such as bronchial asthma 
and emphysema. Its presence is usually pre- 
sumptive evidence of a disqualifying condition. 
In many tall hyposthenic youths, however, the 
conus may be especially conspicuous, and when 
there was no obvious organic cause for this, 
the condition was regarded as normal. 

Simple right ventricular enlargement, — Such 
enlargement without other signs of cardiac 
disease, an extremely rare finding, was reported 
only 3 times. In each case there was a scoliosis 
of the thoracic spine with convexity toward the 
right, without apparent shift of the medias- 
tinum. The border of the right ventricle was 
especially prominent both on fluoroscopy and 
on roentgenograms. The condition was not 
considered to be disqualifying. 

Widening of the aorta. — Increased width of 
the aorta is not uncommon in the older age 
groups, and a moderate degree of uncoiling of 
the ^orta is a normal finding. The differentia- 
tion between widening of the aortic shadow as 
the result of such uncoiling and true enlarge- 
ment or dilatation of the aorta may sometimes 
be difficult. The diagnosis of simple uncoiling 
can be made by examination in the three posi- 
tions. The aorta is actually lengthened rather 
than widened. The apparent widening is due 
to a change in position of the arch as it passes 
diagonally backward. The Hodges-Eyster tables 
could be used satisfactorily here in the deter- 
mination of the size of the aortic shadow. A 10 
percent variation was permissable, and appli- 
cants of the 45- to 55-year age group were 
accepted if there were no other cardiovascular 
abnormalities. Widening of the aortic shadow 
in young men was always considered to be 
suggestive of organic disease, disqualifying for 
military duty. 

Cardiothoracic ratio. — The ratio of the wi 
of the heart to the width of the thoraj*^.'^ 
normally from 0.5 to 0.6, depending upoi^ 
constitutional habitus of the individual q 
lective Service Medical Boards applied 
lower figure, although 0.55 was perhaps m ^ 
accurate. ^ 

Surface area of the heart. — This proced^if^ 
was perhaps the most accurate in determinin 
relative and absolute changes in the size of the 
heart shadow. Using either the orthodiagram 
or 6-foot film, the exact area was measured with 
a planimeter and compared with the predicted 
tables. A 5 percent variation was permissible 
In every instance where cardiac size is im. 
portant in diagnosis, measurements of the 
surface area of the heart should be more 
widely employed, for by this means it was 
possible to detect small changes in the size of 
the heart occurring during an episode of acute 
rheumatic fever or following a myocardial 
infarction. It was likewise valuable in correlat- 
ing the findings in cases presenting questionable 
murmurs or borderline hypertensive syndromes. 

Dextrocardia. — The diagnosis was readily 
confirmed by roentgenogram; many instances 
were noted on routine photofluorographic films. 
These men were disqualified only for the special 
services such as the Air Corps or submarines. 
Two general types of dextrocardia were noted, 
the more benign showing complete transposi- 
tion of the chambers and great vessels (situs 
inversus). When there were no other cardiac 
anomalies, these men were considered to be 
qualified for limited service. The other general 
group had rotation of the heart without trans- 
position, usually in association with one or 
more additional congenital cardiac defects. 
These men were rejected for military service. 

Congenital configurations. — A group of about 
36 young applicants showed unusual configura- 
tions of the heart or aorta or both, in the 
absence of murmurs or other evidence of heart 
disease. The most common abnormal configura- 
tion suggested coarctation of the aorta, ^vhile 
others resembled intraventricular septal defects 
or patent ductus arteriosus. In the absence of 
other objective evidence of congenital heart 
disease nearly all of the men were accepted. 

B Undiagnosed mediastinal changes, — A few 
m^i, none of whom had symptoms of any kind, 
B^wed unusual and unexplained mediastinal 
^adows. Changes in hilar shadows without 
apparent cause also presented diagnostic prob- 
lems in the examination of the cardiac sil- 
houette. Most of these men were accepted. Un- 
fortunately, the cases were not followed. 


The exercise tolerance test was used routinely 
in the examination of all men suspected of 
having hypertensive or coronary artery disease. 
It was also widely employed in doubtful cardiac 
conditions in order to intensify a murmur or 
cardiac irregularity, and permit study of the 
heart under strain. Actually, it was necessary 
to complete any cardiovascular examination 
inasmuch as it was not only a measure of myo- 
cardial reserve but also permitted a study of the 
heart under conditions of stress. The applicant 
was required to perform 10,000 foot-pounds of 
work, any convenient stairs being used after 
the height of the steps had been measured to 
obtain the numerical constant. Blood pressure, 
pulse, and respiratory rate were taken before 
the test, immediately afterward, and following 
3 minutes' rest. 

In the older age groups, the exercise tolerance 
test was probably one of the most important 
examination procedures in determining poten- 
tial or actual coronary artery disease. In addi- 
tion to the measurement of blood pressure, pulse 
rate, and dyspneic index, electrocardiograms 
were taken before and directly after the test. 
It was noted that depression of the ST segments 
in leads I and II could be seen after exercise in 
subclinical types of coronary insufficiency. At 
the Army and Navy General Hospital, Hot 
Springs, Ark., it was observed that the tests 
of the anoxia gave graphic evidence of early 
coronary and myocardial insufficiency even 
when all other studies were normal. Precordial 
pain, with or without anginal radiation, that 
Was promptly relieved by nitroglycerin, was 
evidence of coronary artery disease. 


Rheumatic heart disease, — The combined sta- 
tistical data from various naval facilities 



showed that of 21,210 patients with rheumatic 
fever who were treated in the period from 1942 
to 1945, 2,014, or about 10 percent, had heart 
disease. This compared with 36 percent in a 
Philadelphia population series and 47 percent 
in a New York study. The latter series included 
children, who constitute a group not seen in 
naval statistics. Nearly 3,200,000 days were 
lost because of rheumatic heart disease. Acute 
myocarditis without valvular lesions was noted 
in 73 patients; in 30 there was evidence of 
pericarditis. A diagnosis of pulmonic valvular 
disease was made 3 times and of ulcerative 
endocarditis 23 times. Three patients with 
mitral valvular disease died, out of a group of 
1,436. Grifhth and Huntington reported the 
deaths of three patients from acute anaphylac- 
tic coronary angiitis superimposed upon a low- 
grade rheumatic carditis. 

In recognition of the important role played 
by rheumatic fever in the development of heart ' 
diseases, the Navy set up a special hospital at 
Corona, Calif., for its study and control. Be- 
ginning in 1943, a well-organized program was 
developed for treatment and rehabilitation of 
rheumatic cardiac patients. 

A study made of acute rheumatic fever at 
Brooklyn Naval Hosiptal during the winter of 
1941_42 showed that in an unselected group of 
100 patients, 82 had a history of one or more 
previous episodes, 11 had a primary attack, and 
the remaining 7 offered a doubtful history. In 
32 patients heart murmurs were noted on 
admission to the hospital. Of the remaining 68 
patients, 41 developed murmurs during the 
period of observation. Many patients were 
admitted with pain in one or more joints, slight 
rise in temperature, and a moderately elevated 
white count. Often no cardiac signs were noted 
until the fourth or fifth week, when a soft 
systolic murmur could be identified for the 
first time. In some there was no electrocardio- 
graphic evidence of myocardial involvement, 
but more frequently the diagnosis was con- 
firmed by changes in the P-R interval, which 
often varied from day to day. 

Hypertension, — The group with high blood 
pressure was second in frequency to the rheu- 
matic heart patients seen in the cardiac wards 
of naval hospitals. These were divided into two 



general classifications : paroxysmal or psycho- 
somatic hypertension; and essential, organic, 
or malignant hypertension. As a rule, the for- 
mer was observed in the younger age groups 
and the latter in patients from 35 to 60 years 
of age. There were many instances, however, 
\\here paroxysmal hypertension was found in 
the older age groups. Malignant hypertension 
was infrequently found in young men because 
this condition would have been noted at the 
enlistment examination. 

Paroxysmal (functional or psychosomatic) 
hypertension comes into inominence during 
every war and was considered an integral com- 
ponent of the ''soldier's heart." Together with 
tachycardia, precordial pain, and sweating 
hands, it was a familiar picture, masquerading 
under a variety of names such as neurocircula- 
tory asthenia, effort syndrdme, or psychic car- 
diopathy. Patients with this condition were 
classified as having a psychosomatic disturb- 
ance of the cardiovascular system. 

This type of hypertension occurred in emo- 
tionally unstable individuals. The systolic pres- 
sure was noted in some cases to be as high as 
190 mm. but the usual range was from 150 to 
170 mm. Only occasionally was the diastolic 
level involved. A diagnostic finding of consider- 
able importance was the great liability of the 
systolic levels, which might vary by as much 
as 30 mm. on repeated readings taken within 
an hour's time. 

In a study of 312 such cases observed at 
St. Albans Naval Hospital, most of the patients 
were admitted with a diagnosis of arterial hy- 
pertension. During the observation period of 10 
days to 2 w^eeks, the blood pressure fell to 
normal limits and most of the subjective com- 
plaints cleared up, but after the patients were 
discharged, the entire syndrome, in many in- 
stances, recurred within a few days or weeks. 
In a test series of 50 such patients, 31 were 
readmitted to the hospital once, 11 were read- 
mitted twice, and 7 had 4 admissions for hyper- 
tension. One patient was readmitted 5 times. 

The disposition of patients diagnosed as psy- 
chosomatic or functional hypertension pre- 
sented a serious problem. Not all had person- 
ality defects but a definitive psychiatric aber- 
ration was common to most. In addition, evi- 

dence accumulated to indicate that such i^^ 
viduals subsequently had sustained hype^tejj' 
sion as a result of secondary changes in the 
kidney and peripheral vascular tree. 

Coronary artery disease. — In one form or 
another, coronary disease made up the third 
largest category of cardiac disorders seen ij) 
naval hospitals. While most of these patients 
were in the older age groups, a number of 
relatively young patients were also noted 
Coronary artery disease, confirmed at autopsy 
was reported in 11 patients ranging in age 
from 22 to 38. 

Myocardial infarction following aiKJxia was 
not usually fatal. In many instances the infarct- 
ed areas were subendothelial, and electrocardio- 
graphic changes were not always present. Con- 
stitutional reactions such as increased white 
blood cell count, elevated sedimentation rate, 
and fever were usually absent or minimal. 

In acute coronary occkision, with actual 
blocking of a major artery resulting in myo- 
cardial infarction, the familiar clinical pic- 
ture was noted of pain, profound shock, ele- 
vated temperature, increased white blood cell 
count, and elevated sedimentation rate, in ad- 
dition to characteristic electrocardiographic 
changes. Some patients with coronary insuf- 
ficiency had no pain. In the determination 
of myocardial reserve, electrocardiographic 
changes were observed in patients who only 
had dyspnea or a sense of weakness after the 
test. Ordinarily these changes, such as STi 
depression, returned to normal within a short 

Oppressive and continuous heat, high humid- 
ity, and inadequate water and food supplies 
plagued the first of the Navy and Marine Corps 
personnel to re ach the Solomon Islands. As the 
tropical acclimatization process became better 
understood, the effects of sun exposure and 
water loss were more easily controlled. 

Insofar as cardiovascular disease was con- 
cerned, experience soon demonstrated that per- 
sons with heart involvement fared poorly 
the Tropics. The factors of heat, humidity, in- 
adequate nutrition, and disturbed water metab- 
olism, together with the physical and mental 



rdships associated with combat duty, aggra- 
vated pre-existing cardiovascular disease and 
jn many instances initiated it. The findings of 
a study of 100 patients with cardiac symptoms 
;;een during the early Guadalcanal period are 
ghown in table 32. 

TABLE 32. — Cardiovascular diseases observed during 
early Guadalcanal period 


I Neurocirculatory asthenia - 34 

9 irregularities of the heart: 


A. Extrasystoles 17.0 

B. Paroxysmal auricular fibrillation 3.5 

C. Persistent auricular fibrillation 2.5 

D. Paroxysmal tachycardia 2.0 

E. Heart'block .6 

F. Miscellaneous -5 26 

3 Valvular heart di.sease 20 

I Arteriosclerotic heart disease 11 

5' Hypertensive heart disease 6 

6. Peripheral vascular disease 3 

Total- 100 

Neurocirculatory asthenia was the greatest 
single cause of cardiac disability in the 
Tropics. The syndrome was easily recognized 
by the three outstanding symptoms of per- 
sistent tachycardia with rates as high as 140, 
palpitation, and some degree of breathlessness 
even at rest. 

Sinus tachycardia was not an uncommon 
finding in personnel in the Tropics. Heat, 
physical exhaustion, and tropical diseases, all 
played a role in the development and continu- 
ance of high pulse rates. The tachycardia in 
neurocirculatory asthenia, however, was usu- 
ally out of proportion to the extracardiac stim- 
ulus, and carotid sinus pressure was ineffective 
in reducing the heart rate. Nearly all these 
patients at one time or another presented a 
systolic murmur of varying intensity and dur- 
ation ; the cause of this murmur was not clear. 
The character of the murmur changed with 
alterations in posture as well as during the 
respiratory cycle, and was regarded as func- 

A group of 21 men with moderately severe 
neurocirculatory asthenia, all of whom had 
seen action in the Guadalcanal campaign, were 
studied to determine their fitness for further 
combat duty. The standard work test estimated 
in foot-pounds performed in a given unit of 
time was employed with interesting results. 
After the equivalent of 5,000 ft./lb., two of 
these patients were forced to drop out because 

of breathlessness. After 10,000 ft./lb., six 
others complained of extreme dyspnea and pal- 
pitation. Eleven reached their tolerance be- 
tween 12,000 and 15,000 ft./lb., one-half of 
them showing signs of early pulmonary edema. 
The remaining 2 men finally stopped after 16,- 
000 ft./lb., both with severe precordial pain 
and extreme dyspnea. In contrast, a group of 
10 normal young men were studied using the 
same tests, all of them reaching the 20,000 
ft./lb. standard without unusual cardiovascu- 
lar symptoms. The pulse rate response in the 
two groups was characteristic and striking. In 
the patients with neurocirculatory asthenia, 
the average pulse rate before the tests was 122 
and after the tests 154. In the normal group 
the pulse rate was 74 before exercise and 96 

Irregularities of the heart such as prema- 
ture contractions, paroxysmal auricular fibril- 
lation, persistent auricular fibrillation, par- 
oxysmal tachycardia, and heart block were 
seen in about one-fourth of the patients ad- 
mitted with a diagnosis of cardiac disease. In 
a number of instances a previously undiscov- 
ered cardiac abnormality was found to be 
responsible for the development of these dis- 
turbances of rhythm. Under the stress of tropi- 
cal combat duty the underlying disease process 
had become accelerated. A large psychosomatic 
factor was present in nearly all of the patients 
who had extrasystoles and paroxysmal auricu- 
lar fibrillation. 

There was a need here for a well-planned 
program to investigate the temporary and 
long-term effects of tropical environment upon 
the aging cardiovascular system. This type of 
climate in time of peace, freed of the various 
infections and infestations of the jungle, 
should be theoretically beneficial for the coro- 
nary group of heart diseases. There was con- 
siderable clinical evidence to support this 
opinion. In a superficial survey, a number of 
military and civilian personnel with a previous 
history of angina volunteered the information 
that while in the Tropics they had been more or 
less free from cardiac pain, notwithstanding 
the increased physical effort demanded by their 
jungle assignments. Early in the war the inci- 
dence of coronary artery disease in the Tropics 



was as high as 11 percent, but later statistics 
showed a drop to 2.2 percent, concomitant with 
improved living conditions in the combat zone. 

Hyperteyision was found in 6 percent of the 
patients with cardiovascular abnormalities. 
This group was about equally divided between 
the juvenile types of high blood pressure and 
those hypertensive individuals with associated 
heart and kidney disease. 

Because of the pronounced emotional strain 
of combat duty, there were many instances 
w^here the systolic levels w^ere initially high. 
In a series of 18 young patients seen after 
battle, 1 had a pressure of 220/104, another 
had 212/110, a third had 204/98, 6 were in 
the 190-200/96-98 group, 4 were in the 180- 
188/94-96 group, and the remaining 5 had 
pressures in the range of 160-178/90-94. On 
leaving the line, they all showed a marked 
reduction in systolic levels, sometimes as much 
as 50 mm. within the first 24 hours of obser- 

Tachycardia was present in nearly all of the 
patients with psychosomatic hypertension, but 
the pulse rate usually fell to within normal 
limits after a day or two of rest. No extra- 
cardiac cause for the rapid rate could be de- 
termined, and there was no obvious correlation 
between the pulse rate and the blood pressure 
levels. Electrocardiograms taken on 7 patients 
with psychosomatic hypertension and an ele- 
vated pulse rate showed only a simple sinus 

Of 11 members of this group on whom exer- 
cise tolerance tests were carried out at the end 
of a 10-day observation period, 8 revealed a 
rather typical delayed return to a normal pulse 
rate and blood pressure after exercise. Ten 
showed exaggerated blood pressure response 
after 20,000 ft./lb. of work, compared to 5 nor- 
mal individuals of the same age, height, and 
weight in whom the response was an average 
elevation of only 20 percent. 

An opportunity was thus presented to test 
under combat conditions the general conclu- 
sions drawn during the enlistment study of 
juvenile hypertension. Experience proved that 
such men were poor military personnel who 
fared badly under the emotional and physical 
stress of battleline duty, and that they should 

be rejected for service regardless of the xti^^ 
or less normal interim blood pressure lev i^ 
In selecting young men for service in the ^fo 
oi" Marine Corps, the highest rather than th 
lowest blood pressure determinations should 
be the basis upon which acceptance is ma^^ 

Hypertension in the older age groups )vas 
noted in about 3 percent of cardiac admission- 
In a group of 11 selected for special study, the 
average age was 52; the oldest was 59 and the 
youngest 46. The highest blood pressure was 
210/114 and the lowest was 162/98. 

In contrast to the young hypertensive pa. 
tient, few of the older men complained of symp- 
toms directly related to the higher blood 
pressure levels. In several instances the discov. 
ery of the hypertension was unexpected, ad- 
mission diagnosis in all 11 patients having 
been related to abnormalities of the heart, kid- 
ney, or lungs, or to combinations of these. Four 
patients had increasing edema of the ankles 
and lower legs, two had substernal distress 
after effort, two had severe dyspnea, and one 
each had palpitation, asthma, and lumbar pain 
as the predominant disabling symptom. Head- 
aches, dizzy spells, visual disturbances, in- 
somnia, and other complaints which played such 
a conspicuous role in the juvenile group were 
absent here. 

No vascular accidents from hypertension 
were seen in the combat area, but two men 
had hemiplegia. No conclusions could be 
drawn regarding tropical combat duty as a 
predisposing factor to hypertension. Insofar as 
the older patients were concerned the incidence 
of hypertension (8 percent) appeared to be less 
than in similar age groups reported within the 
continental United States (6 percent at the 
Brooklyn Naval Hospital). It is possible, how- 
ever, that there were many undiscovered cases 
of asymptomatic hypertension among combat 

Tropical wfections and cardiovascular dis- 
ease, — The most frequent tropical disease was 
malaria. During the early phase of the Pacific 
war almost 75 percent of all personnel had 
single or multiple infestations. Improved 
malaria control measures and the use of ata- 
brine as a suppressive drug eventually reduced 
the incidence of malaria to insignificant levels, 



Ithough more than 100,000 cases were re- 
J^j^ted from 1942 to 1945. Nearly all of the 
^aths from cerebral and myocardial involve- 
ent were due to Plasmodium falciparum. 

In a study of 100 men with malaria ad- 
mitted to the hospital in the Guadalcanal area, 
the diagnosis in 26 percent was abdominal dis- 
ease, in 21 percent a cardiac lesion, in 21 per- 
cent bone and joint conditions, and in the re- 
jnainder chest, cerebral, and kidney diseases. 
In a series of 21 patients with malarial involve- 
jjient of the heart, 7 had angina pectoris, 4 had 
coronary occlusion, 2 had paroxysmal tachy- 
cardia, and 1 had auricular fibrillation. Five 
patients had premature contractions and 2 had 
heart block. In each instance, the disease re- 
sponded dramatically to antimalarial treat- 
ment, and there were no deaths. 

In a cardiovascular study of 680 patients 
with dengue, the most common disturbance 
was bradycardia with rates as low as 48. Con- 
duction defects noted in a number of ECG's 
were prolongation of the P-R interval and 
widening of the QRS complex. Arrhythmias 
were chiefly caused by premature contractions, 
which were mostly ventricular in origin. Pre- 
vious observations on patients with postinflu- 
enzal heart disease suggest that the cardio- 
vascular symptoms occurring in dengue may be 
caused by an excessive vagal response to virus 


The cardiovascular system was profoundly 
affected by exposure to continuous cold and 
high humidity. Experimental data secured 
from studies under simulated subarctic con- 
ditions showed that the work of the heart in 
a cold, damp atmosphere was increased by as 
much as 110 percent over that required by the 
same exercise tolerance test performed under 
ordinary conditions of temperature and hu- 
midity. The increase in cardiac work demanded 
by a given test was dependent primarily upon 
relative humidity, rather than upon tempera- 
ture, until -10° F. was reached. Further reduc- 
tion of temperature below that point produced 
physiologic changes that were unrelated to the 
saturation coefficient of the air. 

Cardiovascular disabilities noted in the sub- 
arctic zones include valvular heart disease in 
the young and coronary artery disease in the 
older age group. Acute rheumatic fever was a 
frequent disability, while hypertension was 
noted in only a few cases. Peripheral vascular 
disease aggravated by the cold or secondary 
to frostbite was a common occurrence. 

Hypertension as a separate and distinct 
clinical entity was not common, which was 
surprising inasmuch as the initial physiologic 
response to cold and humidity is one of blood 
pressure elevation. Persons with moderately 
elevated blood pressure as high as 170/100 ap- 
peared to fare about as well as other personnel. 
Only two cerebrovascular accidents were ob- 
served and both patients were safely evacuated. 
Paroxysmal hypertension in the younger men 
was less frequent than in similar groups in 
tropical areas. 

Peripheral vascular disease was of special 
interest not only in the frigid zones but on 
all fronts where cold and dampness prevailed 
and personnel had to work in water because of 
military exigency. So-called trench foot was a 
disabling problem as it had been in previous 

During the early part of the North Atlantic 
campaign, the condition appeared among a 
large group of men who were survivors from 
sunken ships. They had been exposed to ex- 
treme cold, in most cases with their lower ex- 
tremities wet with sea water for hours or days. 
Severe reactions had occurred in their feet, and 
subsequent amputation was found to be neces- 
sary in many instances. For this condition, the 
more appropriate name ''immersion foot'' was 
substituted for ''trench foot.'' 

In immersion foot, the primary injury was 
the result of cold, but interference with venous 
return by dependency, immobility, or tight 
clothing was a contributing factor. Feet so af- 
fected were at first swollen, waxy white (ex- 
cept for scattered cyanotic areas), anesthetic, 
and pulseless. After warming they became 
hyperemic and painful. The first or prehyper- 
emic stage lasted from a few hours to several 
days, during which time the feet were cold, 
dry, swollen, numb, and discolored. The second 



or hyperemic stage lasted from 6 to 10 weeks. 
In this stage, the feet were swollen, anesthetic, 
red, and warm, and sweating was usually ab- 
sent. The third or posthyperemic stage lasted 
from weeks to months, frequently with Ray- 
naud-like phenomena and pain and swelling on 
exercise. Tissue damage at times was exten- 

sive, even with good dorsalis pedis pulsatioj^ 
and amputation often became necessary, g 
cause the disability was amenable to prophv 
laxis, serious attention was directed toward the 
prevention of the syndromes; special stock 
ings, boots, and water-repellent clothing wer^ 
devised by the Navy Department. 


Chapter XIX 


Marion B. Sulzberger, Captain (MC) USNR 
Frederick G. Novy, Jr., Commander (MC) USNR 

From the medical point of view, World 
War II might be called the '*War of Derma- 
toses and Skin Reactions/' In no previous war 
had skin diseases, their causes, and the meas- 
ures for their prevention and treatment played 
so significant a role. Those who have neither 
seen the patients nor examined the statistical 
records may find it diflflcult to grasp the fact 
that in many theaters of war from 60 to 80 
percent of men who reported to sick call did 
so because of skin diseases, and that in the 
Pacific theater one-fourth of all medical cas- 
ualties were evacuated because of some form 
of skin damage. It may be imagined that these 
staggering figures for skin diseases represented 
unusually high proportions, and were peculiar 
to particular areas. This notion has some slight 
justification; but even in times of peace, skin 
diseases in both Army and Navy accounted for 
about 10 percent of all patients hospitalized 
and caused approximately 10 percent of all dis- 
ability and ineffectiveness. 

Recognizing, long before the beginning of 
hostilities, the importance and growing threat 
that dermatoses represented, the Medical De- 
partment and its Research Divisions proceeded 
to inaugurate and to foster investigations that 
were designed to shed light on the causes, pre- 
vention, and management of those diseases 
which fall within the specialty of dermatology 
and syphilology. It is not possible to describe 
or list all the dermatologic and syphilologic 
developments within the Navy during the war, 
but this account gives some idea of the vast 
number, the great diversity, and the signifi- 
cance of the dermatologic problems, as well as 
of the steps that were taken toward their solu- 


From the beginning to the end of the war 
there could be no certainty that the enemy 
would not at any moment start to use poison 
gases on a large scale. It was up to the Armed 
Forces and combat agencies to develop and 
maintain the highest degree of preparedness, 
including every possible means of offense and 

Dr. Milton C. Winternitz of Yale University 
Medical School was appointed Chairman of the 
Committee on the Treatment of Gas Casual- 
ties, and later of Division 5 of the Committee 
on Medical Research of the Oflftce of Scientific 
Research and Development. This committee, 
enlisting the aid of many eminent scientists, 
organized what was one of the war's great ex- 
amples of coordinated efforts of civilian and 
military agencies all striving toward a com- 
mon goal. 

Among the investigators working on the 
problems of chemical warfare, were dermatolo- 
gists as well as biochemists, physicists, and 
other scientists, all concentrating on the scien- 
tific and practical studies of the effects of war 
poisons on the skin. The groups participating 
in these coordinated studies were composed 
of representatives of the following agencies: 
the Naval Research Laboratories of the Bureau 
of Medicine and Surgery ; the National Defense 
Research Committee, Committees of the OflSces 
of Scientific Research and Development, and 
the Committee on Medical Research of the Of- 
fice of Scientific Research and Development; 
the Chemical Warfare Service and the Medical 
Department of the U. S. Army; the United 
States Public Health Service, including the Of- 
fice of Dermatoses Investigation ; a large num- 


ber of civilian institutions, including Cornell 
University Medical College, Memorial Hospital, 
New York University Medical College, Johns 
Hopkins Medical School, Columbia University 
College of Physicians and Surgeons, the Rocke- 
feller Institute of Medical Research, University 
of Chicago Medical School, University of Wis- 
consin Medical School, and Harvard Univer- 
sity Medical School. In addition, a number of 
leading pharmaceutical firms participated. All 
these agencies cooperated, not only with each 
other, but with corresponding agencies and 
groups of Great Britain and other of our allies. 

Chlorine-containing gas vrotective oint- 
ments, — The positive results of these studies 
included the following: Before the war, a 
chlorine-containing protective ointment (M4) 
was issued to the Army for use against mus- 
tard gas. The studies by the groups named 
proved that this preparation was unstable and 
corroded and destroyed its metal containers, 
and also that it was extremely irritating to 
human skin. The protective ointment (S461) 
issued by the Navy at that time was shown to 
be less irritating than the Army issue, but it 
too produced some skin irritations. In addi- 
tion, it was dead white and therefore had poor 
camouflage properties, as well as being some- 
what unstable and tending to corrode its con- 
tainers. The development of a new ointment 
required extensive and methodical laboratory 
research on antigas chemicals, on ointment, 
gel, and paste vehicles, on containers and pack- 
ages, and on camouflage colors. Many thou- 
sands of trials were required, first on laboratory 
animals and then on human volunteers under 
laboratory and simulated field conditions. 
Eventually these investigations resulted in a 
substantial improvement in the protective and 
decontaminating ointments issued to Army and 
Navy personnel. 

The new chloroamide-containing ointments 
(Army M5 and Navy S330), while still far 
from perfect, embodied the following advan- 
tages over all former preparations : (a) Their 
proved effectiveness as a protective and as a 
decontaminating agent against most of the 
blister gases, including mustard gas and lew- 
isite; (6) their relative stability under wide 
ranges of heat, cold, or humidity; (c) their 


relative lack of damage to containers wxi^^^ 
all conditions (tropical, arctic, humid, or dry) . 
(cZ) their good camouflage properties and 
color; and {e) most important, the tremendous 
reduction of their irritating properties to 
human skin, even when applied repeatedly at 
short intervals and under tropical conditions 

In the development of these greatly 
proved antigas ointments, all groups and the 
Bureau of Medicine and Surgery were active 
participants. Indeed, a substantial portion of 
the fundamental work and, in particular, of 
the practical assays of the many agents and 
vehicles investigated was carried out under the 
direction of dermatologists with naval person- 
nel on naval volunteers. 

In addition to assisting in the development 
of new chloroamide ointments for protection 
against and early treatment of mustard gas 
and lewisite poisoning the groups listed soon 
turned their attention to the use against ar- 
senical vesicants of the more specific antidote 

When Peters, Thompson, and Stocken of 
England transmitted to the American investi- 
gators their fundamental discovery of the 
dithiol, BAL, the ''Chlorinating Ointment Pro- 
gram'' was already well on its way. The experi- 
mental machinery and facilities and the tech- 
nical knowledge which had been gained was 
of great advantage in the study of the new 
thiol antigas chemicals. Through extensive 
studies by the cooperating groups, the most 
advantageous ointment vehicles were ascer- 
tained and the present stable and remarkably 
effective 5-percent BAL-containing ointments 
for local applications to skin and eyes were 
rapidly perfected and made available. 

The groups which had been organized for the 
development of antigas ointments were able to 
assist in many other projects. Included among 
these were notably the toxicologic, pharma- 
cologic, and clinical studies that led to the 
preparations of BAL for systemic use and in- 
tramuscular injections. As a result of this, 
there was made available to the Armed Forces 
and eventually to civilian medicine the 10-per- 
cent solutions of BAL in peanut oil and benzyl 
benzoate that have proved so valuable in poi^^*- 



Qfiing and side-effects from such agents as 
arsenicals, mercurials, and gold salts. 

Within these cooperative studies were in- 
cluded many problems, the solution of which 
led to the development of gas protective cloth- 
jjig and equipment, nonsensitizing and non- 
skin-irritating respirator masks, and many 
other practical results. Among the studies, 
which may some day be of value to civilian 
medicine, was the demonstration by the Naval 
Medical Research Unit at Cornell Medical 
School and at Harts Island that the new, rela- 
tively nonirritating chloroamide gas-protective 
ointments were also efficacious against experi- 
mental poison ivy dermatitis, and that these 
ointments might prove to have practical use- 
fulness against clinical plant dermatitis as well 
as against important industrial and other al- 
lergens (dyes, et cetera) causing contact 

Moreover, the nitrogen mustards and their 
effects, and the fluorophosphates with their 
most interesting pharmacologic and toxicologic 
properties, were subjected to intensive study. 
In addition, much knowledge was gained re- 
garding the skin and its reactions, including 
new observations on the process of blister for- 
mation ; the many enzyme systems of the skin 
and their responses; the laws governing skin 
penetration by gases and liquids and the in- 
fluences of heat, cold, sweat, and wetness upon 
the rates of penetration ; and the other factors 
determining the varying permeabilities of the 
skin to extrinsic and intrinsic agents. 


It was found that even the best therapeutic 
measures against vesicant agents of chemical 
warfare were effective only if applied within 
2 to 5 minutes after the exposure of the skin 
to the vesicant. Otherwise, exposures of the 
skin to vesicants such as mustard gas or lew- 
isite in liquid form ordinarily led to damage 
closely analogous to that produced by thermal 
injuries — the resulting lesions closely resem- 
.bled so-called mixed second- and third-degree 
turns. Therefore, Division 5, the Committee 
pi the Treatment of Gas Casualties and the 
Committee on the Treatment of Infected 
pounds and Burns, together with the Bureau 

of Medicine and Surgery and other agencies, 
devoted a great deal of time not only to sys- 
temic management but also to development and 
selection of the best external treatment of both 
chemical and thermal '*burns.'' 

For the first time in the history of medicine, 
many hundreds of different types of local reme- 
dies were subjected to controlled studies, first 
on laboratory animals, then on human volun- 
teers. It was in greatest measure due to naval 
medical research using naval volunteers that 
for the first time in the modern study of burns 
it became possible to elicit standard, equal, 
and essentially identical burns simultaneously 
produced on symmetrically situated sites, and 
to thus study in comparative fashion the na- 
tural course of the lesions and to directly com- 
pare the effects and effectiveness of two or 
more external remedies. (Method of 'Taired 
Comparisons'' on symmetrically situated 

A wide range of agents was studied, includ- 
ing local applications of many forms of sulfon- 
amides, penicillin, tyrothricin, silver nitrate, 
balsam of Peru, vioform, and almost all known 
topical antibacterial agents and vitamins, each 
separately in a variety of different vehicles and 
many in various combinations with other 
agents. Many previously vaunted agents and 
indeed many vehicles including plain petro- 
latum and boric acid ointment did not stand 
the test of scientific, objective evaluation, ap- 
pearing to favor infection and retard healing. 

Only one type of treatment consistently 
showed a significant beneficial effect in a large 
series of controlled experiments in which the 
healing times and course were compared with 
those of untreated lesions protected by dress- 
ings under moderate pressure (a form of ''con- 
trol treatment" which regularly gave among 
the best results). This beneficial type of treat- 
ment included all those measures which had in 
common the factors of removal of nonviable 
and necrotic tissue elements, and at the same 
time were bland enough to spare the maximum 
amount of still viable epithelium and other 
tissue constituents. Wet compresses and starch 
poultices would do this, provided the areas 
could be kept constantly wet. 

The best and most practical way in which the 



standard second- to third-degree burn could 
be gently "debrided" and healing accelerated, 

however, was by the use of a method developed 
in animal experiments performed under a Na- 
tional Research Council grant at Yale Univer- 
sity Medical College. This method consisted of 
the daily application of pyruvic acid in 0.1 
molar concentration in a freshly prepared 
cornstarch paste, or rather, "Gel." In many 
hundreds of comparisons, the naval research 
groups were able to demonstrate on human 
volunteers that these applications rapidly re- 
moved slough, were relatively harmless to 
viable epithelium, and markedly accelerated 
healing of the standard burns. 

In further development, the Naval Medical 
Research Unit at Cornell Medical College, New 
York City, and at the U. S. Naval Disciplinary 
Barracks, Harts Island, N. Y., screened dozens 
of different gels and organic acids as unsuit- 
able, but finally demonstrated that the follow- 
ing were among the more convenient prepara- 
tions that could be used as substitutes for the 
somewhat impractical pyruvic acid starch gel. 

1. Phosphoric acid: 

85 percent — 1.71 sp. gr ^i... 6.74 cc. 

Methyl cellulose (25 CPS.) 170.0 gm. 

Water (distmed) 818.5 cc. 

2. Phosphoric acid: 

(85 percent— 1.71 sp. gr.) 27,2 cc. 

KY Jelly (Johnson & Johnson) 1,000.0 gm. 

Further studies of the Cornell Naval Medi- 
cal Research Unit together with the Southern 
Research Institute then succeeded in develop- 
ing the even more practical powders, which on 
the addition of water rapidly formed effective 
acid-containing gels : 

Formula I 

Pyruvic acid 36.8 gm. 

Methyl cellulose 300.0 gm. 

Sorbitol 60.0 cc. 

(Mix one part of this powder with 10 parts 
of water.) 

Formula II 

Phosphoric acid 30.0 cc. 

Methyl ceUulose 300.0 gm. 

Sorbitol 60.0 cc. 

(Mix one part of this powder with 10 parts 
of water.) 

The preliminary studies on the healin 
standard experimental burns already have 
ceived confirmation in clinical trials, but ih 
final evaluation of these preparations i^ tb^ 
local treatment of burns and necrotic wound^ 
still requires their use on large series of suit^ 
able cases. 

Although the further study and careful use 
of these local measures appears to be clearly 
indicated, it is to be emphasized that the use of 
local ''chemical" debridement does, not do away 
with the necessity of other standard measures 
in file treatment of burns and wounds. Thus 
grafting and surgical repair should be carried 
out as early as possible and as extensively as 
indicated (one great value of the method of 
chemical debridement lies in the speed and ef- 
ficacy with which wounds and defects can be 
prepared for the reception of grafts). In ad- 
dition, it is obvious that measures to prevent 
infection, anti-shock and supportive measures, 
and systemic measures to aid repair and re- 
covery must be taken according to indications, 
in conjunction with the local chemical debride- 


Contact dermatitis, one of the most common 
of human ills, plagued the Armed Forces both 
before and during the war. Not only derma- 
titis from plants such as poison ivy, but also 
dermatitis from a large number and variety of 
other external agents had to be studied. As 
would be expected, these forms of contact 
dermatitis were particularly likely to occur 
when the skin was damaged by heat, humidity, 
and friction, or other irritating conditions pre- 
vailing in military service in hot climates. 

Poison ivy dermatitis was controlled by 
eradication of the plant in the vicinity of 
camps and training stations, and by instruction 
of personnel in avoiding contact. Unfortu- 
nately, it was not until after the end of the 
war that the two new effective *'weed killers" 
2-4 D and ammonium sulfamate became avail- 

The following facts were ascertained con- 
cerning poison ivy and plant dermatitis : 



1. Treatment of acute plant dermatitis by 
means of injection of specific extracts is 
unsatisfactory — more cases were made 
worse than were helped. 

2. Prevention by injection or other adminis- 
tration of specific extracts is not gener- 
ally feasible. 

3. Protective ointments are not generally 
useful but can be of some value for a 
short time and under special circum- 
stances, i. e., when large groups of men 
are forced to go through or work in areas 
heavily overgrown with the plants. 

4. The newly developed and issued chloroa- 
mide-containing ointments (M5 and S330) 
were proved experimentally to be rela- 
tively nonirritating to human skin and 
effective poison ivy protective ointments. 
It would therefore, seem logical to recom- 

Imend these ointments for extensive ciin- 
I ical trial whenever it is known in ad- 
I vance that large numbers of persons will 
I be exposed to poison ivy and related 
j plants for long periods of time. 
5. Immunologic relationships and cross sen- 
sitizations and reactions probably occur 
I between many members of the Anacard- 
l iaceae. These include variants of rhus 
[ such as Japanese lacquer, poison ivy, and 
[ also mango, cashew nut, Semecarpus 
\ anacardium nut, and other commonly en- 
[ countered plants and their derivatives. 
- These agents are often encountered in 
the form of exposures seemingly unre- 
P lated to plants, for example the huge in- 
; cidence of cashew-nutshell-oil dermatitis 
in those handling electrical insulation, 
and the dhobie (laundry mark) derma- 
titis seen in India. 
In addition to contact dermatitis from 
plants, the causes of contact dermatitis in the 
service included almost every imaginable agent 
— antimold preparations, insect repellents, 
clothing materials, dyes and finishes, medi- 
caments (sulfonamide- and penicillin-contain- 
ing creams), antifungus powders, respirator 
masks, rubber accelerators, anti-oxidants, and 
even toilet preparations sold in the Ship's Serv- 
ice Stores. It is likely that the incidence of con- 

258015—53 21 

tact dermatitis among personnel was materi- 
ally reduced by the studies of many of these 
items for their skin irritancy and skin sensi- 
tization before their general issue, with the 
resultant elimination of the worst offenders 
and selection of those which proved least 
harmful in the pilot and screening studies. 
These studies, which had to be performed on 
the skin of large numbers of volunteers, were 
carried out extensively under the Research Di- 
vision of the Bureau of Medicine and Surgery, 
principally at Camp Lejeune in North Carolina 
and by the Cornell Naval Medical Research 
Unit at Hart's Island, New York. 

Once the techniques and facilities for such 
screening studies of contact agents had been 
set up, a method was available for ranging, in 
order of their relative irritating or sensitizing 
potentials, a great number of issue substances 
such as clothing dyes, clothing finishes, impreg- 
nating materials, insecticides, and repellents, 
topical medicaments, and many articles of gear 
and equipment. On one occasion, at least, this 
method was called upon to demonstrate that 
Japanese shells which had been dropped into 
the hold of one of our ships did not contain 
vesicant poison gas as had been suspected, but 
contained an explosive which was also a very 
strong skin sensitizer with a high potential for 
producing contact dermatitis in animals and 
in man. 

Contact dermatitis was of itself a major 
problem and affected large numbers of men, 
occurring on all parts of the body, due to all 
manner of causes. This was inevitable when 
one considers that in a very short period of 
time the skins of some 20 million persons were 
suddenly exposed for the first time to a large 
number of new potential allergens and irri- 

All efforts to prevent skin sensitizers or irri- 
tants from being issued or distributed were 
therefore indicated and worthwhile. Moreover, 
contact dermatitis was not only a menace per 
se, but the skin lesions produced by contact 
agents often irritated, complicated, or main- 
tained many other forms of dermatoses, and 
acted as portals of entry for a large variety 
of infections. 




When one considers the importance of ma- 
laria in relation to mosquito bites, of scrub 
typhus (Tsutsugamushi fever) in relation to 
bites of mites, of yellow fever in relation to 
bites of flies, and of typhus in relation to lice, 
it is easy to realize why so much time and 
effort was spent on developing means of pro- 
tecting the skin from biting insects. In these 
studies, the Naval Medical Research Institute 
and the dermatologists of the Navy partici- 
pated with the Division of Entomology of the 
U. S. Department of Agriculture and with the 
other groups previously mentioned, under the 
coordination of Division 5 of the Committee 
on Medical Research. 

As a result of the combined studies and 
notably those of the Naval Medical Research 
Institute, the following insect repellents be- 
came available before the end of the war: 
Rutgers 612; Dimethylpthalate ; and Indalone. 

Some of the newly developed preparations 
gave protection against mosquito bites for 
from 6 to 12 hours— as contrasted with pro- 
tection times of from 1 to 4 hours provided 
by preparations available at the beginning of 
the war. This result was based on (a) exten- 
sive chemical and laboratory studies, (b) large 
scale assays against biting insects on tremen- 
dous numbers of human skins, (c) carefully 
planned field trips and field trials in many 
areas of the Pacific Islands and the tropical 
Americas, and (d) studies of the habits of 
numerous species of biting insects. The pack- 
ages and vehicles proved acceptable to the men 
of Marine Divisions stationed on Guam. 

Included among the other investigations to 
which the U. S. Navy's dermatologists con- 
tributed their share, were studies of tick-repel- 
lent clothing; of methods for using new 
insecticides, notably DDT; and of improvement 
of preparations against scabies, mites, and lice, 
in particular the clinical assays of NBIN for- 
mula consisting of benzocain, 2 percent ; benzyl 
benzoate, 10 percent; DDT, 1 percent; Tween 
80, 2 percent; and water q.s.a.d. 

Many fundamental facts were learned, iiot 
only about the anatomy, physiology, and habits 
of insects but also about the reactions of the 

human skin. Among these were proof of indu 
vidual variations in susceptibility to insect 
bites ; variations in the attraction or repellency 
of the skin to different species of insects ; var- 
iations in the skin's capacity to be protected 
by a given repellent; and the effects of heat, 
moisture, evaporation, and penetration into or 
through the skin in altering the persistence 
of the repellent powers of different odors, 
colors, and emanations of the skins of different 
animals and persons. 


In the Navy, just as in civilian practice, the 
diagnosis "fungus infection of the skin" was 
made too often, both by dermatologists and 
physicians. In analyzing the figures, it must 
be remembered that many other dermatoses 
look much like fungus infections and that 
medical officers were rarely in the position 
to attempt to confirm their clinical diagnoses 
by microscopic examinations or cultures. It is 
undeniable, however, that even if one discounts 
the high figures for fungus infections a large 
percentage of dermatoses were either directly 
caused by fungi or were initiated, aggravated, 
or maintained by fungus infections. 

The Bureau of Medicine and Surgery has 
long recognized the role that fungus infections 
played among personnel on all types of duty 
particularly among those stationed m hot and 
humid areas, assigned to submarmes or work- 
ing in galleys or laundries. At an early date 
during World War II, the dermatologic and 
other talents of the Navy in cooperation vvith 
other services and agencies, such as the Na- 
tional Research Council and several large 
pharmaceutical firms, were set to work on the 
problems of combating fungus infection. What 
is perhaps the most objective scientific study 
ever planned on the prophylaxis of fungus in- 
fections of the feet was carried out by com- 
parative right and left foot assays of various 
preventive measures on volunteers at the U. »• 
Naval Disciplinary Barracks, Hart's Islanfl, 
N Y (method of "paired comparisons" as ini- 
tiated by the Naval Research Unit at Cornell 
University Medical School) . Dozens of prepa- 
rations, powders, lotions, and ointments were 
screened by the "paired comparison" methoo. 



and selected preparations were tested by sup- 
plementary field trials on naval volunteers un- 
der the hot, humid conditions prevailing at the 
Naval Air Stations at Jacksonville and Banana 
River, Fla. Among the preparations that were 
superior to the old issue powders in prevent- 
ing activity of fungus infections of the feet 
were powders containing the fatty acids. The 
best preparation was the undecylenic-acid zinc- 
undecylenate-containing powder. A very close 
second were the preparations containing pro- 
pionic acid and sodium propionate. 

Other naval studies on the problems of fun- 
gus infections included unequivocal verification 
of the old clinical impression concerning the 
substantial prophylactic effects of proper aera- 
tion of the feet, particularly the wearing of 
sandals, as first demonstrated in the Army Air 
Forces at Eglin Field. The prophylactic value 
of drying the feet thoroughly and keeping them 
dry, of wearing correctly fitted foot gear, and 
of meticulous foot hygiene was statistically 
proved and the general ineffectiveness of medi- 
cated foot baths was demonstrated. 

In the sphere of treatment, the old dictum 
that treatment must above all be mild and non- 
irritating was repeatedly confirmed. Bed rest, 
elevation, and soaks in the acute cases, 7nild 
antipruritic powders and lotions and tinctures 
in the subacute ones, and bland softening 
greases such as undecylenic acid ointments in 
the dry cases proved to be superior to strong 
'fungicides'' or '^antiparasitics" for routine 
treatment. If generally adopted, the results of 
the naval dermatologic investigations of World 
War II will bring about a vast reduction of the 
superimposed contact dermatitide resulting 
from too drastic attempts to ''kill all those 


These diseases, particularly in the Tropics, 
accounted for a great many more cases than is 
generally realized. The pyogenic infections 
Were often superimposed upon such diseases as 
prickly heat, intertrigo, fungus infections, 
superficial scratches, abrasions, wounds, and 

In general, the application of local antisep- 
tics, mercurials, sulfur, iodine, in various 


forms, resorcinol, quinolines, sulfonamides, or 
penicillin was, in the Tropics, a two-edged 
sword; whatever antiseptic effects may have 
been present were often offset by irritation and 
sensitization. As a rule, it was preferable to 
rely on the mildest local measures, such as 
cleanliness, immobilization of the parts, and 
soaks or baths. For these, weak solutions of 
potassium permanganate, boric acid, Burow's 
solution, very dilute mercurials, resorcin (one- 
tenth the usual concentration) , or vioform oint- 
ment was employed. Systemic measures in- 
cluded adequate diets, metabolic regulation, 
and administration of penicillin or sulfon- 


Prickly heat. — This is the scourge of those 
who are susceptible and are forced to live and 
work where it is continuously hot and humid. 
Apparently insignificant, its tortures render 
many a good man relatively incompetent or 
entirely ineffective. Moreover, prickly heat in 
one form or another ushers in a great host of 
other dermatoses : pyoderma, the impetigos, the 
furunculoses, the fungus infections, the contact 
dermatitides, the generalized erythrodermas, 
and even localization and exacerbations of 
psoriasis and lichen planus and perhaps also 
drug eruptions. Studies carried out by the U. S. 
Naval Medical Research Unit No. 2 on Guam 
succeeded in uncovering new information about 
prickly heat and its pathogensis. 

On Guam it was found that about 66 percent 
of personnel became affected within 6 months 
of their arrival. There was no significant varia- 
tion of incidence ascribable to sex, complexion, 
or weight. Sun tanning prevented prickly heat 
in some skin areas in some persons at some 
times, but was not universally effective. Fur- 
thermore, careful microscopic studies con- 
firmed that the cardinal lesion of prickly heat 
was probably plugging of the orifice of the 
sweat ducts by horny plugs, and that vesicula- 
tion, irritation, and "internal sweating" oc- 
curred in connection with this. Factors that 
would prevent plugging or remove the plugs 
were then sought, and several promising 
methods of prevention and treatment were 



recommended for further trial. The studies 
have but begun, however, and the new con- 
cepts of pathogenesis must be regarded as 
opening new avenues of approach rather than 
as having brought the problem to final solu- 

Tropical anhidrotic asthenia.— AW studies 
have shown that in any person's responses to 
heat and high humidity, the reactions of his 
skin play a decisive part, because the skm is 
the organ for the dissipation or conservation of 
heat and of fluids. However, it was not until 
the independent studies of workers in the 
American desert, in Australia, and at the U. S. 
Naval Medical Research Unit at Guam that a 
type of "heat shock" was recognized as a sys- 
temic syndrome that could be traced directly 
to a superficial and scarcely noticeable skin 

This disease has been called "tropical an- 
hidrosis" or "tropical anhidrotic asthenia." 
The plugging of the pores (as in prickly heat) 
is, in these cases, so extensive that a substan- 
tial number of the estimated 2 million sweat 
glands can no longer function. The fluid is re- 
tained in vesicles or forces its way into the 
interstices of the tissues below the firmly 
plugged orifices of the ducts. This abnormal 
disposition of sweat causes papule formation, 
itching, and periductal inflammation, with 
sweat resorption by lymphatic channels and 
into regional nodes. Systemically, whenever 
elevations of temperature and humidity call 
upon the individual to make use of emergency 
mechanism of sensible or secretory perspira- 
tion (in addition to the usual constant physical 
cooling devices, such as insensible perspira- 
tion) he is unable to do so adequately and some 
form of collapse ensues. This collapse may be 
associated with sweat pouring from the still 
open glands (usually of the face), accelerated 
respirations leading to hyperventilation, alka- 
losis and sometimes rapid dilatation of the cu- 
taneous vascular bed with a precipitate drop 
in blood pressure. From this brief composite 
description of what was observed in cases on 
Guam and, by others, at the New York Skm 
and Cancer Unit, it is evident that when a 
patient is unable to dissipate heat by the usual 
methods, the body may endeavor to utilize sev- 

such tie 

eral vicarious cooling mechanisms 
rapid respiraton and rapid peripheral vascuia,, 

Recognition of the superficial plugs in the 
sweat glands and of the relationship of the 
histopathologic changes to those of prickly 
heat, has improved our comprehension of this 
disease and its separation from the other heat 
and sun effects (such as heat strokes, sunstroke, 
and dehydration) . The new understanding of 
the role of the skin lesion in producing tropical 
anhidrotic asthenia gives promise of the dis- 
covery of prophylactic measures to prevent the 
plugging and of therapeutic measures to re- 
move the plugs once formed. Correctly ad- 
justed peeling, either with ultraviolet rays 
or chemical keratolytic lotions (salicylic acid 
and resorcinol in alcohol) was of therapeutic 
value not only in prickly heat but also in areas 
of plugging as found in tropical anhidrotic 
asthenia. Permitting men to spend several 
hours of each day in rooms with lowered hu- 
midity and temperature aids in preventing both 
this disease and prickly heat. 

The knowledge gained under the "forced 
draft" of war emergency problems serves as a 
foundation and stimulus to further medical 
research. Thus postwar studies undertaken 
at the New York Skin and Cancer Unit of the 
New York Post-Graduate Medical School and 
Hospital make it seem likely that some every- 
day nontropical skin diseases, which are prone 
to have exacerbations during periods of high 
heat and humidity and which rapidly improve 
on transfer of the patients to places with con- 
sistently low effective temperatures, are re- 
lated to the mechanisms discovered in prickiy 
heat and tropical anhidrotic asthenia. A sig- 
nificant number of such patients with atopic 
dermatitis, mild ichthyosis, and atypical sebor- 
rheic dermatitis were found to have pluggeo 
sweat ducts and consequent disturbances in tne 
ability of the skin to dissipate heat. 

Many more investigations are required to de- 
termine how the repeated abnormal utilization 
of the accessory circulatory and respiratoiy 
mechanisms for heat dissipation may be r 
lated to svstemic disease, especially to thyrw 
and metabolic disturbances and to cardiovascu- 
lar and bronchopulmonary diseases. It is a 



ecessary to study the effects of repeated forc- 
ing of sweat into the tissues. It is conceivable 
that sweat in the tissues may cause a variety 
of skin lesions, such as the vesicles of dyshid- 
rosis, and lichenoid and scaly dermatoses. And 
it is not too farfetched to speculate that when, 
as a result of plugged ducts, millions of in- 
tracutaneous injections of sweat and its solutes 
are made daily, cutaneous sensitization and 
allergic dermatoses to the substances in solu- 
tion might occur in susceptible persons. In this 
way the plugging of sweat glands might favor 
sensitization to foods, drugs, or other materials 
secreted with sweat. This may apply to the ata- 
brine eruptions, atabrine being excreted in sig- 
nificant amounts in sweat. If this hypothesis 
applies, the increased incidence of the lichenoid 
atabrine dermatoses in the same climates where 
prickly heat and tropical anhidrosis are most 
common would be more than coincidence. 


Much knowledge was gained concerning 
drug eruptions, in particular the new and most 
destructive form of atabrine lichenoid erup- 
tions. This condition, which has many elements 
resembling eczema, dyshidrosis, exfoliating 
erythroderma, lichen planus, discoid lupus 
erythematosis, Jacobi's poikiloderma, Riehl's 
melanosis (melanodermatitis bullose toxica of 
Erich Hoffman), and poikiloderma of Civatte, 
was intensively studied and clarified in many 
of its aspects by dermatologists in the Navy. 
In addition, the drug reactions produced by 
local and internal administration of sulfona- 
mides and penicillin were observed and new 
information recorded. Illuminating observa- 
tions on the localization of penicillin eruptions 
in areas prone to be aflfected by primary or 
secondary lesions of fungus diseases were re- 
ported by naval dermatologists. This led to the 
fundamental concept of possible common anti- 
genic fractions in penicillin molds and in patho- 
genic fungi, such as trichophytons; and this, 
in turn, proved a stimulus to research and has 
already produced important new immunobio- 
logic and mycologic findings. 

The studies of sensitization reactions and 
drug eruptions from penicillin and sulfona- 
mides have led to a much more conservative at- 

titude concerning the use of these drugs as ex- 
ternal tropical disinfectants. More intelligent 
and sharply focused criteria for their applica- 
tion have been developed, with a consequent re- 
duction of disagreeable or dangerous sequelae. 

No discussion of the progress made in com- 
bating drug reactions can omit the part played 
by BAL in counteracting the reactions caused 
by arsenicals, mercurials, and gold. The U. S. 
Public Health Service, Johns Hopkins Medical 
College, Cornell University Medical College, 
naval dermatologists, and naval volunteers all 
contributed to the studies of toxicity and hu- 
man tolerance, and in setting up standard dos- 
age schedules for intramuscular administration 
of solutions of 10 percent BAL in benzyl ben- 
zoate and peanut oil. 


The development of more stable and effective 
sulfonamide and penicillin preparations was 
largely a matter of the study of vehicles and 
their effects. The wartime studies, in which the 
Bureau of Medicine and Surgery participated, 
succeeded in improving these vehicles and their 
preparation. Studies were also carried out at 
the Naval Medical Research Institute at 
Bethesda, Md., of effects of heat, light, and 
humidity upon the skin. The development of 
effective antiflash creams to protect against 
this most common of all casualties in aerial at- 
tacks and explosions ; the increased knowledge 
concerning the effects of sunlight and methods 
for assaying and compounding better chemical 
sun screens ; and the improvement in buildings, 
gear, and clothing for use in the Tropics — 
these were but a few of the important results 
of studies made. 


The Navy fully participated in organized 
efforts to improve prophylaxis and treatment 
of venereal disease. Local measures of prophy- 
laxis, methods of rapid treatment, public 
health investigations with careful reporting 
and tracing of contacts, improvement in sero- 
logic techniques, development of better peni- 
cillin preparations, and determination of op- 
timum dosage schedules were actively fur- 
thered by the Bureau and by Medical Depart- 
ment personnel throughout the world. 



Material progress was made in combating 
yaws in native populations in the various thea- 
ters of war, where mapharsen and penicillin 
were shown to be effective in treating this dis- 
ease. Progress was also made in methods of 
diagnosis, prophylaxis, and treatment of chan- 
croid, lymphogranuloma venereum, and granu- 
loma inguinale. . > 


Well aware of the significance of dermatoses 
and of venereal diseases as threats to the 
health and effectiveness of the Navy, the Bu- 
reau of Medicine and Surgery began, long be- 
fore the war, to develop a well-equipped, effi- 
ciently organized, and adequately staffed De- 
partment of Dermatology and Syphilology in 
each of the naval hospitals. 

The facilities never were sufficient during 
the war to meet the huge task, and there were 
never enough specialists and specially trained 
hospital corpsmen and nurses to handle all 
cases, but a tremendous upsurge in the train- 
ing of physicians, hospital corpsmen, and 
nurses continued throughout the war. One 
phase of this effort was represented by the 
Navy and Army dermatologists collaborating 
in the preparation of a '^Manual of Derma- 
tology'' for the National Research Council. 
This publication, issued to all medical officers 
and all naval medical activities, contained in 
concise form the basic information necessary 
for the diagnosis and management of the most 
common dermatoses, together with a simple 
but adequate formulary of useful medicaments. 
The formulary was designed to eliminate as 
far as possible unnecessary ingredients, to in- 
clude only the items immediately procurable in 
sufficient quantities, and to reduce the bulk 
and weight of all required medicaments so as 
to facilitate their transportation and distribu- 

As a result of these combined efforts, the 
Navy's capacity for diagnosis, prevention, and 
management of dermatoses and venereal dis- 
eases substantially improved. While still by no 
means optimal, the development of facilities 
for dermatology and syphilology reached a 
level which was probably higher than that ever 

before attained during a period of active hos. 
tilities in such large and widely disseminated 
Armed Forces. 


In patients returned to the United States 
because of skin diseases, fungus infections 
made up about 29 percent and acne 28 percent. 
Other skin conditions with a high incidence 
were eczema of the lower extremities and ata- 
brine dermatitis. 

Dermatoses from tropical infections were 
extremely rare, if filariasis was excluded. This 
was surprising because the natives of the Pa- 
cific area have many different infectious skin 
diseases. Of 1,047 natives in New Guinea, 43 
percent had cutaneous lesions. There were only 
a few isolated cases of yaws and most of these 
occurred among the medical personnel treating 
natives. Tinea imbricata, so frequently seen in 
the natives of the Tropics, was not reported 
in naval personnel. 

The effect of the tropical climate on skin 
diseases was of great importance and the usual 
dermatoses showed many interesting changes 
from their course in temperate zones. If a man 
had a skin disease on arrival in the Tropics, 
it almost invariably became aggravated. This 
was particularly true of the fungus infections, 
which usually spread rapidly and would not 
respond to ordinary methods of treatment. 
Seborrheic dermatitis did not do well in heat 
and high humidity. Severe forms of acne pre- 
sented many dermatologic problems. Psoriasis, 
another disease thought to be helped by sun- 
light, frequently became worse or else was first 
noted after arrival in the Tropics, while those 
diseases thought to be aggravated by sunlight, 
such as lupus erythematosus and cutaneous 
malignancies, showed no evidence of exacerba- 

It was found that a great deal could be done 
to decrease the incidence of skin disease by 
close attention to personal hygiene. This meant 
at least one or more baths a day with a liberal 
amount of soap. Following this, the body had 
to be thoroughly dried, so that none of the 
surfaces retained the slightest trace of water. 
Particular attention had to be paid to such 
areas as the ears, axillae, groin, genitalia, and 



the interdigital spaces. Following this, the 
liberal use of nonmedicated powder was bene- 
ficial in reducing skin maceration. Daily 
changes of underclothes and socks were neces- 
sary. It was found that changing shoes from 
day to day aided in reducing fungus infection 
of the feet; this was particularly true if the 
shoes could be placed where they would dry. A 
good coat of tan was found to be helpful in 
resisting superficial infection and in some cases 
decreased prickly heat. Salt-water bathing was 
also beneficial if all surfaces, particularly the 
ears, were dried after bathing. 

In general, the treatment of skin diseases in 
the Tropics was similar to that employed in 
the Temperate Zone. There were, however, 
some definite exceptions. Ointments and pastes 
were not well tolerated and shake lotions or 
alcoholic tinctures, powders, and mild wet 
dressings had to be substituted. Also, better 
results were obtained when the active ingredi- 
ents were decreased to one-quarter or one-half 
strength of that commonly used in the cooler 
climates. In the acute phase of any dermatitis, 
extremely mild preparations used as com- 
presses, such as boric acid and potassium per- 
manganate, 1 :20,000, and plain calamine lotion 
or other powdery shake lotions gave the best 

Throughout the war eczematous allergic con- 
tact dermatitis was extremely common. The 
principal cause was overenthusiastic therapy 
with the mercurial preparations and the sul- 
fonamides. The latter in ointment form were a 
particularly common source of dermatitis. 

Anhidrosis. — Under the title of thermogenic 
anhidrosis, a peculiar and severe form of an- 
hidrosis among the troops training in the 
desert occurred after long exposure to the hot, 
dry climate. The face and neck perspired in a 
normal fashion, but there was a failure to 
sweat from the neck down. The skin of the af- 
fected area showed a dry, papulofollicular, 
nonerythematous eruption having a ''goose- 
flesh'' appearance. In addition to the cutane- 
ous manifestations, there was extreme weak- 
ness. Similar cases were observed among the 
naval personnel in New Guinea, where the 
climate was hot and very humid. No apparent 
cause for the anhidrosis was found and the 

patients recovered on removal to a cooler 

Dyshidrosis ( pompholyx or cheiropom- 
pholyx). — This was frequently observed and in 
many persons it persisted throughout their stay 
in the Tropics. It is made up of deep-seated, 
noninflammatory vesicles involving the palms 
and soles. It is nearly always associated with 
hyperhidrosis. These vesicles appear suddenly, 
last for 24 to 48 hours, and then rupture spon- 
taneously, leaving a collarette of fine scale and 
a noninflammatory base. There was never any 
evidence of infection in a true case of dyshi- 
drosis. In differentiating this entity, it is of 
some help to note that in dyshidrosis there is 
no inflammatory reaction and no purulent 

Dyshidrosis is probably closely related to 
prickly heat. On the palms and soles the sweat 
gland orifices are bridged over or plugged by 
squamous epithelium and cellular debris so that 
the gland cannot empty in the normal manner 
and a small cyst is formed beneath the plug. 
This is borne out clinically, in that after the 
vesicles rupture there is no evidence of any 
underlying infection. Persons suflfering from 
this disease continue to have recurrences 
throughout their stay in the hot climate. These 
lesions can become secondarily infected by 
either bacteria or fungi. 

Tropical acne. — This acne differs in many 
respects from the acne vulgaris in the Tem- 
perate Zone. Its onset is more abrupt and the 
individual lesions are frequently of the cystic 
type so that many deep-seated pustules develop, 
resulting in deep scarring. The degree of scar- 
ring in many cases at the end of 8 to 10 months 
correspond to that seen in temperate climates 
at the end of 5 to 10 years. The disease was 
important and was noted in 28.5 percent of all 
patients with skin disease evacuated from over- 
seas. In the older patients, none had had 
trouble with acne for years until going over- 

The lesions of acne appeared within 2 months 
after arrival in the Tropics ; in over 90 percent 
the disease appeared within 6 months. Nearly 
all the patients had a history of mild 
acne. Often in tropical acne the face, which 
showed evidence of previous acne, was not 



affected, suggesting that areas of old acne 
vulgaris were resistant to tropical acne. 

Sites of involvement of tropical acne were 
striking as compared with those of adolescent 
acne vulgaris. By far the commonest sites were 
the back and chest, but the buttocks and thighs, 
or the arms and forearms were mvolved in 
nearly one-third of the cases. These latter two 
sites are unusual in adolescent acne vulgaris. 

The American Negro appeared to be resistant 
to this disease, no cases being observed m 

Negroes. , « 

The most probable cause of this unusual form 
of acne seems to be an overstimulation of the 
sebaceous glands because of the heat, somewhat 
analogous to that which occurs in the sweat 
gland apparatus in prickly heat. The glands 
become plugged with sebaceous material and 
cellular debris, resulting in comedo forniation 
and cysts, which become pustules secondarily. 

While these patients remained in the Tropics 
they became progressively worse. The usual 
remedies for acne vulgaris were of little or no 
avail. Many patients improved rapidly on reach- 
ing a cooler climate but were usually left with 
severe and mutilating scarring in the involved 

areas. . ^ ^. 

Fungus infections.-Mycotic infections of the 
skin constituted one of the major problems 
throughout the war. Diagnosis was usually 
made on clinical grounds rather than on labo- 
ratory findings. The most likely cause for this 
high incidence of fungus infection was the 
humidity and sweat that produced constant 
maceration and thus set up an ideal medium 
for the growth of the organisms. Many of the 
patients gave a history of having had a mild 
infection causing little or no trouble before 
arriving in the Tropics. On arrival, exacerbation 
usually occurred and frequently was so severe 
that it rendered the patient unfit for duty. 
Lymphangitis and secondary bacterial infection 
were common, but could usually be controlled 
bv the use of sulfonamides or penicillin. The 
treatment of ordinary fungus infections of the 
feet in the Tropics was usually unsatisfactory 
and in many instances the patient had to be 
transferred to a cooler climate. Unfortunately, 
the newer preparations such as undecylenic and 
propionic acids and their salts were not avail- 

able in the early part of the war and were not 
in general use even in the latter part. 

Tinea corporis was common among naval pej. 
sonnel, with an incidence much higher than in 
the United States. Large plaques were fre. 
quently noted, some of which were from 10 to 
20 cm. in diameter. These had all the clinical 
characteristics of ordinary tinea corporis seen 
in temperate countries. The border, however, 
showed more induration and was erythematous. 
This condition did not usually respond to ordi- 
nary types of fungicidal preparations. 

Tinea cruris was also seen frequently. The 
incidence among naval personnel was higher 
than that of the Army, possibly due to the type 
of uniform worn in the Navy. This disease 
was secondarily infected, and eczematized easily 
and the entire crural area and inner aspects 
of the thigh and lower abdomen often became 
swollen and covered with a weeping crusting 

Tinea versicolor with its characteristic yellow 
or fawn-colored macules and papules was seen 
in many patients. Many of these patients had 
extensive lesions covering the greater part o 
the tor=o The achromatic type was common and 
frequently mistaken for vitiligo. This type is 
thought to be caused by either a protective 
action of the fungus against light or the para- 
site-producing achromia, possibly through the 
actions of the toxins on pigment or a combina- 
tion of these two mechanisms. 

Tinea imbricata, the spectacular fungus in- 
fection of the natives of the South Pacific 
not reported among naval personnel. Thi. i 
surprising because of the high mcidence of th 
disease among the natives and the fact that th 
scales are loaded with the organisms, so tha 
it would seem that it could easily be transmitted 
to Caucasians. ;« 

The incidence of deep fungus infection in 
the Tropics was extremely low. 

Pyogenic infections—These were common 
following even the most trivial abrasion J_ 
trauma. Excoriations from ^^'^^h itching de^ 
toses as prickly heat commonly became inf ect^ 
producing extensive pyoderma Furuncles jn^ 
carbuncles were frequently noted and becam 
so generalized and ran such a protracte 

lad t 
but i 


of p: 
n te 













course that the patient in many instances 
had to be transferred to a cooler climate. Com- 
plications of these various forms of pyoderma, 
such as lymphangitis and sepsis, were frequent 
but fortunately responded readily to sulfona- 
mides or penicillin. 

Tropical impetigo. — The most unusual type 
of pyoderma seen was so-called "tropical im- 
petigo,'' in reality a form of bullous impetigo. 
In temperate countries, bullous impetigo is an 
extremely rare condition in adults, although 
common in children. In the Tropics, many adults 
were infected. It was frequently secondary to 
prickly heat. Its incidence was extremely high 
when new bases were being formed or when 
troops were under combat conditions. As bases 
became more settled and showers and laundries 
were installed, the incidence dropped. The 
organism most frequently isolated from the 
blebs of this disease was staphylococcus aureus 

Tropical impetigo begins as a small, erythe- 
matous macule which becomes vesicular in a 
few hours. The vesicle or bleb covers the entire 
macule so that there is no surrounding halo of 
erythema. It is thin-walled, filled with a clear, 
straw-colored serum, and at this stage is tense. 
The lesion enlarges further and often reaches 
a centimeter in diameter. The contents become 
purulent and the wall of the bleb or bulla 
becomes flaccid. It is easily ruptured by the 
slightest trauma, such as the rubbing of clothes, 
and leaves a raw, superficially denuded surface. 
The whole process from the appearance of the 
erythematous macule to the rupture of a bulla 
may take only 4 to 6 hours. The infection is 
most contagious and auto-inoculable, so that a 
large number of new lesions may occur over- 
night. The axilla, groin, and waistline are the 
sites most often affected. 

Treatment of the individual lesions is satis- 
factory, but recurrences are common and diffi- 
cult to prevent while the patient remains in the 
Tropics. The use of any mild antiseptic prepa- 
ration will cure the individual lesion. It is 
important that the patient be seen and treated a 
Jiumber of times a day, so that a lesion does not 
rupture and auto-inoculate another area. In 
extensive cases, the injection of 20,000 units 


of penicillin every 3 hours for a total of 140,000 
units was advocated. 

Tropical ulcer. — The term tropical ulcer was 
widely used to cover any type of ulcerative pro- 
cess. Most of these ulcers were not of a specific 
nature such as those of syphilis, yaws, or lepro- 
sy. They were in reality ecthymatous ulcerations 
of the extremities, usually following some type 
of trauma or insect bite. They failed to heal 
because of the climatic conditions and because 
many of the patients remained in ambulatory 
status. Another frequently noted factor which 
delayed healing was dermatitis venenata from 
too-strong medications. Sulfonamide ointments 
were the principal offenders. With wet dress- 
ings of a concentration of 2,500 units of peni- 
cillin per cc, the ulcers healed rapidly. 

Before the war, several different types of 
tropical ulcers were described. They were par- 
ticularly prevalent throughout the Solomon 
Islands, New Guinea, and the PhiHppines. Many 
of these showed an infection with Vincent's 
organisms, namely, Spirochaeta and fusiform 
bacilli. Some harbored pseudodiphtheria bacilli 
and some were attributable to true diphtheria. 
A number of authors believed that an inade- 
quate vitamin intake was the underlying factor 
of many of the ulcers. Other ulcerative erup- 
tions of the Tropics have been described under 
the titles of desert sore, veld sore, and Barcoo 
rot. Various bacteria such as staphylococci and 
streptococci have been isolated by different 
workers. Others believed that excessive expo- 
sure to sunlight was important in the produc- 
tion of the condition. These eruptions begin as 
vesicles which may rapidly become bullous and 
soon rupture, leaving a dirty, punched-out ulcer. 
There is little tendency to heal and they may 
slowly extend at the margin. There is an asso- 
ciated folliculitis. The ulcers in these categories 
usually occur on the hands and forearms. Most 
of these lesions respond readily to cleanliness 
and weak antiseptic dressings. 

Cutaneous diphtheria. — Cutaneous diphthe- 
ria, for some still unexplained reason, is fre- 
quently encountered among the natives of the 
Tropics. During the war, only a few cases 
occurred in Navy personnel. This may have been 
because most of the men had good living condi- 



tions. There were two large series of cases 
reported froTn the Army. The first 174 cases 
were reported from the Solomon Islands, Sai- 
pan, and Leyte. The second group of 140 cases 
were reported from the India-Burma theater. 
The lesions were noted mostly among combat 
troops who had been away from adequate bath- 
ing facilities for a long time. 

Cutaneous diphtheria frequently begins in a 
pre-existing bite or abrasion, but may start 
without any definite preceding lesion, it is 
usually an ulcerative process primarily involv- 
ing the epidermis and subcutaneous tissues and 
rarely going deeper. The ulcer is covered with 
a vellow-brown membrane which can be peeled 
off, leaving a clean-appearing, hemorrhagic sur- 
face. Later a brownish-black slough is found. 
A wide band of inflammatory reaction usually 
surrounds the ulcer. In later stages, the ulcers 
have a punched-out appearance. On spontane- 
ou.. healing, blebs may develop in the scar tissue 
which, in turn, break down forming a new 
Xilcer Most frequently, the lesions, which are 
usually multiple, are on the legs and feet. 

The bullous eczematoid and intertrigolike 
forms of diphtheria, not unknown in the civilian 
practice of dermatology, were either wctremely 
rare in the Armed Forces or escaped correct 

'^''compUcations of cutaneous diphtheria are 
polyneuritis and myocarditis. In one report 34 
percent of the cases had polyneuritis and 2.7 
percent had myocarditis. Treatment for this 
disease includes large doses of antitoxin, to 
prevent systemic ill effects, and pemcilhn. 

ContacMype allergic eczematous dermattm, 
dennatiti. venenata.-ln the Tropics there are 
a number of plants that produce an acute der- 
matitis in susceptible individuals, most of them 
belonging to the family of Anacardtaceae. Thi^ 
dermatiUs venenata is similar to that produced 
by poison ivy or poison oak in this countiT^ 
Cases of dermatitis caused by the sap of he 
tree SemecarpvMtam, were reported from the 
South Pacific as well as others clue to the laun- 
dry mark (dhobie mark) made from the oil of 
nuts from the bella gutti {Semecarpus anacar- 

dium) tree. , 

In the author's experience, there was only 
one group of Seabees working in the forest who 

developed a typical allergic eczematous contact 
dermatitis from the flora. Some types of mili. 
tary equipment caused many cases of contact 
dermatitis, however, and dermatitis from ex- 
ternal medication, insecticides, clothing, equip, 
ment, and cosmetics was of high incidence. Per. 
sonnel on duty in the Tropics were niore sus- 
ceptible to skin damage and to skin sensi- 
tizations than the civilian population in tern- 
perate climates. 

Schistosoma dermatitis.— This dermatitis is 
caused by the entry of cercariae or larvae into 
the skin following bathing in polluted fresh 
water. It begins a short time after coming out 
of the water as a tingling sensation on the parts 
of the body that have been submerged. It is 
followed by pruritus and the appearance of 
small red macules. In a few days these may 
look like chigger bites. Later a severe urticaria 
may appear and the edema may last several 
days. The importance of this dermatitis is that 
it may be the prodromal symptom of schistoso- 
miasis. A number of cases of this dermatitis 
were observed among men stationed in the 
Philippines, particularly on the islands of Leyte 
and Samar. 

Dermatitis of the dorsa of the feet and ankles. 
-This condition has also been referred to as 
-boot dermatitis" or "bootlike dermatitis" or 
sometimes "stocking dermatitis." During the 
war it was extremely common among naval per- 
sonnel in the Tropics. Unfortunately, its cause 
could not be discovered. Most observers beheved 
that it was definitely not a fungus infection. 
The process usually started on the dorsa of the 
feet and the sides of the ankles. This spread and 
often involved all of the dorsum of the foot and 
lower leg. It was frequently bilateral. Later 
there might be an acute, eczematous reaction 
with marked edema, weeping, and crusting. 
This was easily infected secondarily and lym- 
phangitis occurred, necessitating hospitaliza- 
tion. After the acute stage was controlled or 
subsided, lichenification set in, associated witn 
persistent and severe pruritus. Excoriations 
from this might, in turn, become infected. 

These lesions usually were not associatea 
with the ordinary interdigital fungus infection. 
In fact, the interdigital areas were often pecu- 
liarly free. Some believed that this eczematow 



reaction began with a fungus infection, but, 
either through too-vigorous medication or from 
heat edema of the foot, a secondary dermatitis 
developed. It appears plausible, however, that 
heat and moisture plus abrasion from the shoes 
and socks produced the eruption. Standing for 
long hours on duty must have also played a 
part. Some observers found that the men were 
sensitive to the leather of the Marine type of 
field boot, but could not be sure that this was 
the factor in the allergic contact dermatitis 

Treatment was unsatisfactory. Even the 
mildest antiseptic solution would aggravate 
and spread the lesion. These patients frequently 
had to be returned to a cooler area and even 
then required a long period of treatment. 


The most interesting new dermatosis seen 
in tropical areas during the war was the un- 
usual and spectacular eruption which has now 
been proved to be caused by the ingestion of 
atabrine (quinacrine hydrochloride). It is to 
the credit of the dermatologists caring for 
these patients that they realized almost at once 
that they were seeing a unique eruption and 
that atabrine was the major factor in its pro- 
duction. This is substantiated by the many dif- 
ferent reports that were made. 

The first cases were recognized in the early 
part of 1943. They were noted in widely sepa- 
rated hospitals but the patients all came from 
the New Guinea, North Solomons area. One 
report described three cases of exfoliative der- 
matitis caused by atabrine. They had all had 
suppressive atabrine treatment for malaria. 
One patient had an exacerbation of his eruption 
on retaking the drug, and all had a positive 
patch test to the drug. 

Similar cases were reported among Austra- 
lian troops coming from New Guinea. They pre- 
sented an unusual dermatitis and had been tak- 
ing atabrine. Later in the same summer, cases 
Were observed among Army and Navy person- 
nel who had been evacuated from tropical areas 
because of skin diseases. Proof that atabrine 
elicited such eruptions was obtained in 12 
patients ; in 3, patch tests with atabrine were 


positive, and in 6 or 8, exacerbations were noted 
following administration of atabrine by mouth. 

These cases were first described as a typical 
"hypertrophic lichen planus.'' Because most of 
them came from New Guinea, it became known 
as *'New Guinea lichen planus'' or ''New Guinea 
disease." At first it was believed that the en- 
vironment in New Guinea had something to do 
with its development. The role of environment 
was soon disproved when other cases appeared 
wherever adequate dosage of atabrine was 
taken over long periods. Likewise, the theory 
that the eruption was caused by vitamin defi- 
ciency was weakened when the eruption ap- 
peared among those receiving well-balanced 
diets with plenty of fresh foods. Similar cases 
but in fewer numbers were reported in the 
Mediterranean and India-Burma theaters. As 
the war progressed, new cases appeared among 
the military personnel in the Philippine Islands 
and later in Okinawa. 

Incidence, — Fairly accurate figures on the 
incidence of this drug eruption have become 
available. The estimates of maximum occur- 
rence vary from 2 to 10 per 1,000 per annum. 
It was reported that more than 80 percent of 
the Army patients evacuated from New Guinea 
for skin diseases had this lesion. 

Incubation period, — One of the most interest- 
ing facts concerning atabrine dermatitis was 
that sometimes there was an extremely long 
interval before full development of the typical 
picture. Few cases developed soon after taking 
the drug; the great majority of the patients 
did not develop any type of characteristic erup- 
tion until they had been taking ''suppressive" 
atabrine for from 3 to 8 months. 

Clinical appearance, — Patients developing 
this type of dermatitis often first noticed scal- 
ing areas associated with pruritus, particularly 
about the eyes, over the knuckles, about the 
ears, and in the corners of the mouth. At first 
only one or two lesions appeared and then new 
areas were slowly involved. The lesions were 
sharply demarcated papules with dusky red, 
erythematous bases having a fine scale. About 
the ears, the early lesions showed diffuse scal- 
ing, some edema, and a characteristic purplish- 
red color. 



In many patients, eczematoid eruptions of 
hands and feet preceded the lichen lesions ; in 
others there were widespread eczematoid and 
exfoliating erythrodermas which sometimes 
preceded the lichenois dermatosis and some- 
times persisted with few, if any, lichenoid 
changes. As the lichenoid disease progressed, 
new areas were likely to appear anywhere on 
the body. The neck was frequently involved and 
there was a tendency for the lesions to be oval, 
with long axes following the lines of cleavage. 
They were usually about 2 cm. in diameter. In 
some of the older lesions, the appearance of the 
scale was that of slightly dirty mortar. Often 
these oval lesions following the lines of cleav- 
age suggested pityriasis rosea, but the deeper 
color and type of scale and induration of the 
papules differentiated the disease. 

The disease did not progress rapidly, but 
after a few weeks the lesions became larger 
and confluent, forming patches. This was par- 
ticularly noticeable on the lower legs and the 
backs of the hands. In more advanced cases 
showing large patches, there was a tendency 
to secondary eczematization because of the 
excessive heat and moisture of the Tropics. In 
locations such as the axilla and inner aspect of 
the thighs, there was a great deal of edema, 
weeping, and crusting. Pyoderma was a fre- 
quent complication. On the scalp there was 
often a thick dry scale, which in many instances 
suggested psoriasis. Alopecia was associated 
with this, together with apparent atrophy sug- 
gesting lupus erythematosus. 

Interspaced between the larger plaques, par- 
ticularly on the neck, a definite follicular, papu- 
lar noninflammatory eruption was noted. This 
had a dry scale and was suggestive of phryno- 
derma or vitamin A deficiency. The toe and 
finger nails were frequently involved. In the 
early stages a purplish-black line occurred at 

the proximal portion of the nail bed. In some 
patients this was the only manifestation of 
atabrine intolerance. The mucous membranes 
were sometimes affected with purplish-black 
discolorations and occasionally there were le, 
sions of the mucosae similar to those of lichen 

Some authors have attempted to differentiate 
the types of eruptions caused by atabrine into 
the eczematoid and hypertrophic lichen planus, 
like forms. These different types were actually 
due to the location. The eczematoid were seen 
in areas such as the axillae, the circumanal 
area, and about the genitalia where there was 
secondary maceration from profuse sweating. 
The hypertrophic form was usually seen on the 
extremities and the head. Patients nearly al- 
ways showed both eczematoid and hypertrophic 

Many patients had generalized exfoliative 

dermatitis with loss of finger and toe nails 
and generalized alopecia. In this severe form, 
the absence of sweating was noted in the in- 
volved areas. In some instances death resulted 
from the exfoliative dermatitis. On stopping the 
drug, most patients gradually improved, how- 
ever, over a period of months, but in many there 
was residual apparently permanent atrophy of 
the skin, pigmentation, and partial alopecia. 

In this country, patients with this type of 

dermatitis who had been returned from over- 
seas were observed. Patch tests with atabrine 
were of no aid in making a diagnosis, only 
about 20 percent reacting positively to patch 
tests, but many dermatologists observed that 
on readministration of atabrine there was a 
definite exacerbation of the eruption. It can be 
regarded as proved beyond reasonable doubt 
that this cutaneous syndrome is due principally 
to specific sensitization to atabrine. 

Chapter XX 

Medical Research 

Harold W. Smith, Rear Admiral (MC) USN (Deceased) 

Notwithstanding all the efforts that preceded 
•'Pearl Harbor/' the outbreak of hostilities 
found us unready. We had no information as 
to the area of major effort, and little warning 
as to possible hazards to be encountered. Lack 
of information was felt particularly in the 
diversified Pacific Ocean area; the ''iron cur- 
tain" over the Japanese mandates had resisted 
penetration, so that, while the diseases in that 
area were known in general, their exact distri- 
bution had not been charted or the local habits 
of vectors studied. Effective means of control 
for each locality had to be learned. Even a 
disease as familiar as malaria was to take enor- 
mous toll, in some instances paralyzing a cam- 
paign, before efficient suppressive measures 
came into general use. 

The weapons used by the enemy, although 
known in advance, were used in novel ways or 
in novel situations, so that medical service had 
to be adapted to new defensive measures. New 
tactics, as exemplified in the amphibious assault, 
required new systems of medical supply, first 
aid, evacuation, and protection. It was for the 
protection of assault troops that body armor 
was developed. The first task devolving on 
medicine was selection of personnel ; its second, 
to devise practicable means of protecting per- 
sonnel from the innumerable environmental and 
occupational hazards to which they would be 

In medicine, as well as in the sciences of 
combat, advances made in the intervals between 
wars are so considerable that the implements 
and procedures employed in one war are super- 
seded in the next. That proved true at the very 
outset of World War II. New measures had to 
be selected from among those immediately avail- 
able, and the manner of their utilization pre- 

Material for selection was incomplete, how- 
ever, and much was untried. During the period 
following World War I, research had been 
desultory and progress irregular. In only a 
few instances, had it reached the definitive 
stage. The exigency did not permit further 
reference to fundamental research, so there was 
urgent need for an agency capable of quickly 
mobilizing the potential of the country to supply 
authoritative advice and to fill gaps in existing 
knowledge. Accordingly, by Executive Order 
No. 8807 of 28 June 1941, there was created 
within the Office of Emergency Management 
(the 0. E. M.) the Office of Scientific Research 
and Development (the 0. S. R. D.) ''for the 
purpose of assuring adequate provision for 
reseach on scientific and medical problems . . 

Under the Director, Dr. Vannevar Bush, 
there were set up two branches— the lay Na- 
tional Defense Research Committee (the N. D. 
R. C), Chairman, Dr. James B. Conant; and 
the Committee on Medical Research (the C. M. 
R.), Chairman, Dr. A. Newton Richards. The 
medical committee, whose function it was to 
advise and assist the Director in the perform- 
ance of his medical research duties, consisted 
of seven members, including one each from the 
Army, the Navy, and the Public Health Service. 

In order that the C.M.R., a small group, 
should be in position to tap the resources of the 
whole country, it established organic relations 
with the Medical Sciences Division of the 
National Research Council (the N.R.C.). Dr. 
Lewis H. Weed, chairman of the N.R.C., 
promptly organized about 50 committees and 
subcommittees, members of which were se- 
lected from universities and other institutions. 
Representatives of the Armed Forces were 
present at all meetings, and informational 
liaison was established with our allies. 



The committees furnished opinions, defined 
problems requiring investigation, formulated 
attacks, and weighed proposals for research, 
recommending those advanced by individuals 
and institutions who were adjudged qualified 
to undertake the studies proposed. The propo- 
sals were next considered by the C.M.R., and 
those recommended by that body were then, 
with the approval of the Director, negotiated as 
contracts by the Administrative Division of the 

Malaria proved so devastating in the earlier 
years of the war, at a time when stocks of 
quinine were dwindling, that the C.M.R. set up 
a special group — the Board for the Co-ordina- 
tion of Malarial Studies. This Board furnished 
an example of the *'team'' or group research 
- which has been so productive for industry and 
which proved equally successful in malariology. 
Drugs of value in the many-sided control of 
malaria were developed through the joint ef- 
fort of clinician, chemist, parasitologist, phar- 
macologist, toxicologist, immunologist, and 
manufacturer. This concerted form of attack 
presents a model of the approach indicated in 
the future for the solution of the many com- 
plex problems still crying for elucidation. 

Meanwhile, the Navy was active in its own 
right. The Bureau of Medicine and Surgery 
established a Research Division charged with 
maintaining liaison, collecting information, and 
initiating, implementing, coordinating, and uti- 
lizing all medical research. The conviction lead- 
ing to the creation of this division was that by 
research as by no other means could the con- 
servation of forces, the mission of the Medical 
Department, be served. Events justified this 
belief. Although combat theaters included re- 
gions saturated with factors of morbidity. 
World War II was the first great war in history 
in which the damage suffered from enemy 
agents exceeded that from disease. 

A collateral function of the Research Divi- 
sion was to acquaint personnel in the field, who 
were often removed from other sources of in- 
formation, with new developments pertinent to 
their varied tasks — often years in advance of 
publication. This valuable service was ade- 
quately performed during the war by a bi- 
weekly ''news letter/' 

Combat requirements were studied by special 
laboratories, suitably located, dealing with the 
particular problems of aviation, field opera, 
tions, submarines, biological weapons, and 
chemical warfare. Special groups for special 
purposes were organized from time to time. For 
consultation, reference, and reinforcement, and 
for basic or other indicated research in the al- 
lied sciences, the Naval Medical Research In- 
stitLite was built at Bethesda, Md. 

In rapid succession 11 medical research units 
were set up. They were primarily concerned 
with investigation, development, application, 
and field studies, but turned to basic research 
when it was the only known approach to the 
solution of an urgent problem and whenever 
pursuit of a personal speculative interest was 
compatible with obligations to implement the 
war. There were, too, many incidental develop- 
ments bordering on pioneer research : there was 
no novelty in the transfusion of blood, but it 
was trail-blazing to make **fresh'' whole blood 
available throughout the jungles of the Pacific. 

In many lines of investigation, the Navy was 
in a favored position to undertake research, be- 
cause it had facilities and other enabling re- 
sources not available to civilians. For example, 
the huge aggregations of personnel at training 
stations under complete control afforded unique 
opportunity for studies in communicable dis- 
ease, a fact which suggests practical criteria 
for allocating tasks to the Armed Forces and 
to civilian research agencies respectively. 

It will be conceded that civilian institutions 
are usually better equipped and more ably 
staffed for basic research. They can furnish 
highly competent specialists, as they did dur- 
ing the war, whose skills can be utilized for 
special services of one kind or another. For any 
study within a Navy frame, however, as in the 
case of an item to be carried through the 
sequences of development, adaptation, trial, and 
adoption, the Navy alone has the familiarity 
with the field of application which from the 
start must govern the development and also the 
material resources necessary. In such a case, the 
military organization concerned should have 
full direction and control. 

While the demands of war limited **pure" 
research by the Navy, it is gratifying to note 



that, since the war, the Office of Naval Research 
has embarked on a policy of supporting **basic 
research with freedom in its conduct/' This 
course was adopted because of the realization 
that from the mass of knowledge so accumu- 
lated may come the weapons and defenses of 
the future. Provision was made for medicine 
by a Medical Science Branch in charge of a 
medical officer attached to the Bureau of Medi- 
cine and Surgery. - ' *• - ^ • • 

Overseas laboratories were commissioned at 
Guam and at Cairo, Egypt, to cover tropical and 
subtropical latitudes, thus giving the Navy con- 
tact with many diseases for the most part 
strangers to our homeland but certain to be 
encountered in the course of a global war and, 
at all times, possibly pandemic. 

Employment of animals for the study of new 
compounds is a first step, but before the adop- 
tion of a new drug is justifiable, data concern- 
ing its pharmacology, toxicology, and thera- 
peutic action must be corrected or confirmed 
on human subjects. Such procedure is not 
devoid of danger, and commendatory mention 
should be made of the inmates of naval dis- 
ciplinary barracks and of civilian institutions, 
who, although fully informed as to possible 
hazards, volunteered to serve as subjects for 
the final studies on new and unproved drugs — 
particularly antimalarials, fungistatics, and 
wound dressings. These men, barred from other 
war service, patriotically viewed the ordeal as 
their contribution to the war effort. 

To make foreign liaison effective, medical 
officers were attached to the U.S. Embassies in 
London and Moscow. Various officers served 
on occasion with the Office of Strategic Serv- 
ices and with Bombing Surveys in Europe and 
Japan. A British medical officer occupied an 
office in the Bureau, and Canadian officers were 
in daily communication. 

It has been remarked that during the war 
there was no research, that what passed for 
research was, in fact, development and applica- 
tion of products of prior peacetime. That state- 
ment is too sweeping; numerous instances to 
the contrary can be cited, but in large measure 
it is true. Urgency did not permit resort to 
so-called fundamental research, the results of 
which cannot be foretold, much less its duration. 

No reproach can attach to such policy, for 
it is obviously necessary to adopt something of 
some value that can be used immediately, rather 
than gamble on the outcome of a program which 
may yield something of more value at some 
indeterminate date. The principle, ''conserva- 
tion of forces,'' must determine the action to 
be taken, and observance of that principle 
brooks neither compromise nor delay. For this 
reason — pressure for research of more im- 
mediate promise — the vitally important study 
of man with reference to his genetic constitu- 
tion and its highly variable response to environ- 
mental influences had to be postponed for the 
time being. 

Nevertheless, in many instances it was pos- 
sible to carry on basic studies, often simul- 
taneously with use of a product guided by such 
information as was already available. Penicillin 
is an example. At the same time that its ther- 
apeutic spectrum was being learned by clinical 
trial, studies bearing on selection of strains, 
culture methods, constituent substances, and 
chemical synthesis were being pushed vigor- 

The elaboration of antimalarials is another 
case in point. Although quinacrine hydro- 
chloride (atabrine) had been proved generally 
superior to quinine and was in use, investiga- 
tion continued, some 15,000 compounds being 
synthesized and their action studied. In the 
welter of substances isolated, a few with true 
plasmocidal action were discovered and new 
light thrown on the life history of the different 
species of Plasmodia within the human host. In 
fact, attainments in this field tempt one to spec- 
ulate on the extensions of which war research 
may be capable: the economic, social, and 
anthropological effects of virtual extinction of 
malaria are beyond reckoning. 

It may not be amiss to consider what lessons 
for our future guidance may be derived from 
our recent experience. One debated question is : 
to what extent should the Government support 
the pursuit of knowledge for its own sake in 
time of war? Although history contains in- 
stances of discoveries which at first sight appear 
to be isolated phenomena, inquiry shows that 
few if any were made without reference to the 
sustained interests and occupation of the dis- 



coverer. If not the direct issue of planned re- 
search, they were incidental to research, inves- 
tigation, or pursuit of some recognized ob- 

Research carried on without reference to a 
specific objective will, if in sufficient volume, 
eventually yield results which constitute addi- 
tions to knowledge and for which, it may be 
presumed, a use will ultimately be found. But 
this proceeding is slow, costly, and uncertain; 
and even if successful, integration or applica- 
tion may be delayed for centuries. Unless re- 
search is conditioned by prospective application, 
it tends to become anchoretic. 

During the late war, the fields in which ac- 
complishment was noteworthy were those in 
which objectives were formulated by directives 
and research prescribed accordingly. There- 
fore, in case of urgent need or of a novel de- 
velopment, mastery of which is essential to na- 
tional security, objectives should be imposed 
and tasks assigned. 

Another lesson learned, although its validity 
will be heatedly disputed, is that in event of war 
only ''the military'' are familiar with all consid- 
erations bearing on justification of develop- 
ment and practicability of adoption. Hence, in 
all organized bodies set up by the Government 
for the underwriting of research related directly 
or indirectly to military operations, statements 
as to needs, determinations of relative import- 
ance, judgments on proposals, in fact, all deci- 
sions as to action to be taken, should be made 
by officers of the Armed Forces. They should, 
however, be sitting in joint session with civil- 
ians qualified to advise on matters within their 
respective areas of cognizance and to set in 
motion whatever research is deemed desirable. 
Research in such case has a special purpose and 
cannot be carried on productively unless sub- 
servient to that purpose. 

Although in time of war over-all direction of 
research should be entrusted to the military, 
that is a policy dictated by time and circum- 
stance. Through the years, both medical and 
military science will be genuinely advanced al- 
most wholly by the labors of civilians. On the 
other hand, the Government now accepts the 
obligation to foster basic research, and appro- 
priates funds to be expended for that purpose 

in its own laboratories and in civilian institu. 
tions. Hence, it is to the mutual advantage of 
the Government and civilian research workers 
that close relations be maintained through com. 
mon membership in Councils, Societies, and Na- 
tional Foundations, by cooperative association 
with Government agencies, and by personal con- 
tract or other form of periodic employment by 
the Government. In truth, it is not merely a 
matter of mutual advantage ; it is an obligation 
a group owes its Government and the Govern- 
ment owes to the people. 

It now seems a curious fact that prior to the 
war the engineer, the architect, and the opera- 
tions officer proceeded with little reference to 
the human organism. For among the more sig- 
nificant and fruitful developments of the war 
period was the recognition that came to be ac- 
corded to contributions that specialist officers 
of the Medical Department could make to en- 
hance efficiency — human data as factors in en- 
gineering and design. 

Broadly speaking, the function of the Medi- 
cal Department is still to conserve military 
strength by ensuring that there shall be no 
avoidable loss in personnel or diminution in its 
efficiency, but for the accomplishment of that 
mission new tasks have emerged. Whereas prior 
to the war the guiding principle, *'conserva- 
tion,'' found its chief expression in a striving 
for the mastery of disease, during the war that 
particular field of activity became relegated to 
secondary importance, it having been found that 
the inactivation of personnel by enemy agents 
exceeded that due to disease or intrinsic dis- 

That outcome was not due to accident or to 
chance conjunction of circumstances. Knowl- 
edge already possessed, research in many quar- 
ters, and intelligent application in the field 
combined to effect the high degree of disease 
control. The unprecedented achievement is a 
monument to preventive medicine — to the re- 
rearch teams, to the planners and administra- 
tors, to those who applied principles to terrain, 
to the construction battalions who remade 
topography to order, and to those in authority 
who understandingly gave their support. 

The very success of preventive medicine led. 
however, to its partial eclipse, for it gradually 

.: ' ; ; - . .■ ■■ ' MEDICAL 

came apparent that a greater measure of con- 
^^^rvation could be gained by the linkage of 
jnedicine to industry and to the combat branches 
of the Navy in the design, development, pro- 
duction, and employment of the engines, 
vseapons, and devices used in v^arfare, and by 
contributing the special knowledge of medicine 
> the formulation of decisions governing 

rategy, tactics, campaign planning, and sup- 
ply. This shift in emphasis has been visibly 
accelerated by the revolutionary changes in 

Because the principle, ''conservation and ef- 
ficiency,'' demands that the active list be cleared 
of ineffectives, the retention in a naval hospital 
of patients who cannot be returned to full duty 
in a reasonable time can be countenanced only 
when the vital interests of the patient require it 
or when other Government facilities are lack- 
ing. Hence the conception of a noncombatant 
branch dedicated solely to the relief of suffering 
is obsolete, and strictly professional activities 
become at best a service of first aid, salvage, 
and morale. Today, then, the Medical Depart- 
ment is to be viewed as an auxiliary corps 
having positive and direct part in promoting 
military eifectiveness, and its policies are to be 
formulated accordingly. 

As already noted, each war is waged with new^ 
developments, and it is upon research that the 
nation must rely to keep its military ways-and- 
means modern throughout the years. Indeed, the 
more the military establishment is reduced, the 
more imperative it is that purposeful research 
be supported without stint. 


In order to do that, it is necessary that re- 
search, owing to its highly specialized and pro- 
gressively sequential nature, be administra- 
tively independent of current operational 
policies. That principle is embodied in the top 
organization of both the War and the Navy 
Departments ; a like policy is no less incumbent 
on the Medical Department. 

Further, as a means of self -propagation, the 
function of training is inseparable from a serv- 
ice as peculiarly specialized and diversified as 
research. Particularly is it important in the 
case of a Navy operating from pole to pole that 
training be carried on in the so-called ancillary 
sciences which together constitute the science 
and art of medicine. Fortunately, the necessity 
of training is now a fixture in Navy practice and 
is implemented by congressional appropriations. 
It is a function which cannot be allowed to 

Research is the one instrumentality by means 
of which we can forecast particular develop- 
ments of the future and at the same time ar- 
range that the future shall be as we anticipate 
it in those respects. Witness the atomic bomb. 
Experience is no acceptable substitute. Granted 
that experience is the great teacher, it may be 
so catastrophic as to destroy its victims. In any 
event, it becomes available only post facto. It is 
hindsight. Given new conditions such as are met 
in each successive war, experience is as yet 
unborn. Research remains the cheapest, quick- 
est, and surest means to industrial progress 
and military strength. . ■ . 

258015—53 22 

Chapter XXI 

Clinical Psychology in the Screening Program 

William A. Hunt, Commander (MSC) USNR 

Both World Wars witnessed significant de- 
velopments in psychology. World War I saw the 
coming of age of the group testing movement 
and the development of the now famous Army 
Alpha and Army Beta group tests of intelli- 
gence. World War II saw the maturation of 
clinical psychology as a specialty, with stress on 
individual testing techniques and supplemen- 
tation of test scores by the clinical interpreta- 
tion and judgment of the trained specialist. 

The great success of group tests of intelli- 
gence in World War I led to their subsequent 
overevaluation. Many psychologists believed 
that the problem of measuring intelligence had 
finally been mastered by a completely objective 
technique. Here were simple paper-and-pencil 
exercises which could be administered to large 
numbers of individuals simultaneously by rela- 
tively untrained personnel and scored auto- 
matically to yield an accurate measure of 
intellect. It was a mechanical process that 
could be handled by anyone, without the inter- 
vention of highly trained professional per- 

As time passed, however, group tests were 
found to have their limitations. They were 
reasonably accurate when used on average men 
of normal intellect and temperament, raised 
in a common cultural environment with equal 
educational opportunity and tested under 
rigidly standard conditions. When applied to 
the deviant individual, the educationally and 
culturally handicapped, the mentally deficient, 
the emotionally unstable, the neurotic and 
psychotic, and the person suffering from some 
organic brain condition, group tests proved to 
be fallible and relatively unenlightening. Yet, 
it is these persons on which it is vital to have 
accurate information. 

As a result, those psychologists serving in 
behavior clinics, court clinics, and psychiatric 

hospitals came to rely upon the individual test, 
a test that is administered in a face-to-face 
situation to a single subject and is not limited 
to the use of paper-and-pencil materials. In 
such a situation, the examiner is able to con- 
trol the testing conditions more carefully, to 
introduce any variations demanded by the spe- 
cific condition of the person being tested, and 
to complement the resulting test score by his 
clinical observation of the subject's behavior 
during the test. Moreover, it is then possible 
to evaluate the subject's test performance in 
relation to his personal history and any fur- 
ther clinical data that are available. Such a 
complete evaluation cannot be rendered by any 
mechanical testing device, but only by a trained 
clinician exercising professional judgment. 

By the advent of World War II, there had 
developed a group of clinical psychologists 
skilled in the use of individual testing tech- 
niques and in the clinical interpretation of the 
test results. Their contribution was recognized 
by psychiatry and they were experienced in 
working with the psychiatrist and neurologist 
as members of a clinical team. It was inevitable 
that they should be included when the Bureau 
of Medicine and Surgery began to develop a 
program of neuropsychiatric screening to 
obviate those difficult problems of military 
neuropsychiatry which World War I had 
demonstrated must be anticipated in the rap- 
idly developing emergency. 

Group tests for intelligence and aptitude 
retain an important place in naval procedure, 
but are relegated to the Classification Depart- 
ment, where they are used for job selection and 
placement. When the problem of further refin- 
ing these rough measures arises, as it does in 
differentiating mental deficiency from cultural 
or educational handicap, or in establishing 
mental deficiency as reason for separation from 



the service, the case is referred for individual 
testing by the clinical psychologist. 

The original plan for neuropsychiatric 
screening envisaged a psychiatric unit composed 
of a psychiatrist, a neuropsychiatrist, and a 
clinical psychologist who would function as a 
diagnostic team. It was seldom possible to 
maintain this exact ratio, but these three com- 
plementary disciplines — psychiatry, neurology, 
and psychology — were always represented. 

The duties of the psychologist in this team 
were delineated in a statement entitled, *'Basic 
procedure for psychologists functioning at 
training stations and Marine Corps bases in 
connection with psychiatric units," which was 
enclosed with a directive on neuropsychiatric 
screening issued 1 February 1941. This direc- 
tive assigned to the clinical psychologist the 
task of evaluating ability and temperament. 
Certain standard individual tests, such as the 
Wechsler-Bellevue Adult Intelligence Scale, 
were suggested as basic procedures, but pro- 
vision was made for the addition of other tests. 
The psychologist was further instructed ''to 
collect data on such scales'' in order that they 
might be improved and new ones devised, thus 
providing a research function in the improve- 
ment of current testing techniques and the de- 
velopment of new ones. 

It was recognized that in the evaluation of 
ability and temperament the psychologist 
should go beyond the mere test scores and 
utilize his clinical interpretation of the ex- 
aminee's behavior and history— The psycholo- 
gists selected for work in the Medical Corps 
will have had considerable training and experi- 
ence in interviewing, counseling, the interpre- 
tation of social histories, as well as of strictly 
psychological tests. Therefore, their findings 
should prove a valuable supplement to those of 
the psychiatrists." 

The general procedures established for neu- 
ropsychiatric screening are dealt with exten- 
sively in another chapter. In review, they 
provided for a brief neuropsychiatric examina- 
tion of all incoming recruits, an observation 
ward where those recruits suspected of unfit- 
ness could be held for detailed case study, and 
an Aptitude Board empowered to pass on the 
findings of the psychiatric unit and to recom- 

mend separation from the service to the Com 
manding Officer. Later directives instructed 
that a psychologist should serve as one mem. 
ber of this Board, and defined the psychologist 
as ''adjunct" to the psychiatrist, to serve under 
his direction. This was not meant to minimize 
the value of the psychologist's work or to limit 
his initiative ; it was a recognition of the fact 
that in a medical situation responsibility must 
rest in a medical officer, to be delegated as he 
sees fit. The psychologist thus worked under 
and reported to the psychiatrist. In most sta- 
tions where more than one psychologist was 
on duty, it became the custom and practice of 
the senior psychiatrist to recognize psychology 
as an informal division or department and to 
hold the senior man responsible, as senior psy- 
chologist, for the activities of his group. 

These directives established a general frame- 
work for the screening program, but wisely 
allowed great latitude in the working out of 
details. In part, this was necessary to meet 
adequately the particular problems of each 
local command and to allow the flexibility 
necessary for solving the novel problems that 
were bound to arise suddenly as the war pro- 
gressed. In part, it was an attempt to recognize 
the personal responsibility and to encourage the 
professional initiative of the psychologist and 

The first time the psychologist was called on 
to assist the psychiatrist in his diagnostic 
duties was during the initial screening inter- 
view given each recruit upon his arrival at the 
training station. Here, the stress was on brev- 
ity, with the actual interview averaging only 
2 or 3 minutes. While men suspected of unfit- 
ness could be held for further observation, such 
facilities were limited and such observation 
represented a serious interruption of the re- 
cruit's training. Thus, the initial interview had 
to be decisive if possible, and carried great 
authority. A psychologist was always present 
for on-the-spot testing whenever this was indi- 
cated. With sometimes as many as 40 or 50 men 
per day being referred to him for testing as 
they passed down the examination line, it was 
necessary for him to adapt his procedures to 
the same pattern of brevity and incisiveness 
that was demanded of the psychiatric interview. 



fhe extent of the problem becomes apparent 
\vhen we remember that the classical individual 
intelligence test as used previously in civilian 
{practice might require 45 minutes or an hour 
. administer and longer to score and interpret. 
,n hour per man v^as impossible on the screen- 
ing line! 

Before the war, relatively little v^ork had 
een done on abbreviating the standard indi- 
vidual testing techniques. The problem of vol- 
ume in civilian practice, when it arose, was 
handled by a resort to group tests. Where some 
abbreviated individual tests had been tried out, 
the normative material used in developing in- 
terpretative standards frequently was based 
on children and was not suitable for use with 
adults. One exception was the Kent Emergency 
Test mentioned by the original directive, but 
even this received further shortening for mili- 
tary purposes, until it finally emerged as a test 
of only 10 items. 

Faced with the necessity of developing their 
own short test forms, the naval psychologists 
solved the problem with alacrity, and many ab- 
breviated intelligence tests were produced. One 
typical battery consisted of the 10-item Kent 
Emergency Test, a brief test of verbal opposites, 
and 2 written tests — a 2-minute arithmetic test 
and a 2-minute test involving the carrying out 
of certain easy directions. These 4 tests com- 
prised a battery which could be administered 
and scored within 10 minutes, and adequately 
duplicated for screening purposes the perform- 
ance of the longer, standard tests. In some in- 
stances where the pressure of work became too 
great, it was necessary to resort to mass group 
testing as a preliminary screening device to 
select those subjects in need of subsequent in- 
dividual examination. 

The detection of mental deficiency was an 
important one for the Navy. We must realize 
that large numbers of the country's feeble- 
minded are never institutionalized and that this 
is particularly true of the higher grade, bor- 
derline cases. Any system of recruiting or 
drafting large numbers of the population must 
inevitably draw in a fair share of such incom- 
petents. During 1942 it was estimated at the 
Newport Naval Training Station that between 
2 and 3 percent of the incoming recruit body 

were mentally deficient. This is about what 
would be expected in view of what is known of 
the incidence of mental retardation in the popu- 
lation at large. It is worth noting, however, that 
only about half of these were being separated 
from the service. The other half represented 
high-grade morons of borderline intelligence 
who seemed suitable for service by reason of 
particularly stable personality and previous 
training. Even so, those discharged represented 
at that time about one-third of all separations 
from the service by reason of inaptitude. 

The psychologist sometimes was thought of 
as an overzealous individual lurking in the 
screening line ready to pounce avidly upon any 
victim who could possibly be called feeble- 
minded. The truth was the exact opposite of 
this. The presence of the psychologist with his 
objective testing devices actually saved many 
more men than it condemned. The diagnosis of 
mental deficiency is a difficult one to establish 
quickly, and the harassed psychiatrist working 
at top speed often mistook educational handi- 
cap, physical fatigue, emotional upset, or indi- 
vidual peculiarities of personality for genuine 
intellectual retardation — a false impression 
which testing was able to correct on the spot. 

Impaired intellectual performance or deficit 
is a function not only of mental deficiency, but 
also of the deterioration accompanying mental 
disorder and many cases of organic brain dam- 
age. Intelligence tests are particularly sensi- 
tive to such deterioration, which appears in 
peculiar, atypical test responses not character- 
istic of ordinary feeblemindedness and often 
specific to the particular pathosis involved. It 
is thus possible to use the results of intelligence 
testing as a diagnostic aid in establishing the 
presence of psychosis or organic brain condi- 
tion. Many of the cases referred for testing 
in the screening line were referred for this 
reason, and the test results plus the clinical 
interpretation of the psychologist often resulted 
in substantiating a difficult diagnosis for the 
psychiatrist or neurologist. Such diagnostic po- 
tentiality in a test was one further requirement 
that had to be satisfied in developing abbrevi- 
ated testing techniques for neuropsychiatric 

The development of personality tests has no- 



toriously lagged behind that of tests for intel- 
ligence. Moreover, the more reliable individual 
testing instruments used for the analysis of 
personality, such as the Rorschach, have not 
yielded successfully to the demands of abbrevi- 
ation. As a result, few tests of temperament 
were used on the screening line, being largely 
reserved for the more leisurely procedure of 
the observation ward. 

An exception to this was the development of 
the various neurotic inventories used in detect- 
ing the presence of psychopathosis of many 
types. These were paper-and-pencil group tests, 
most of which in essence called for the sub- 
ject to check the presence or absence of signifi- 
cant symptoms such as enuresis, sleepwalking, 
and feelings of depersonalization, as well as 
clinically significant factors in his personal his- 
tory such as educational achievement, stability 
of employment, and a police record. 

Tests were developed which w^ere highly suc- 
cessful in detecting the unfit, their efficiency 
sometimes operating as high as 80 or 90 per- 
cent. Their great handicap lay in the fact that 
most of them had a high false-positive rate, 
i. e., they incorrectly identified as unfit a num- 
ber of individuals who were fit. Because of this, 
they were used only as preliminary screening 
devices for the selection of those recruits need- 
ing further individual examination. The final 
determination of neuropsychiatric unfitness al- 
ways issued from an individual psychiatric ex- 
amination, but such preliminary sorting devices 
developed by the psychologist lightened the 
burden of examining for the psychiatrist and 
permitted him to concentrate his efforts where 
they were most needed. 

Most naval psychologists employed in the 
selection program experimented at some time 
with such tests. Among the more popular ones 
were the Cornell Selectee Index and the various 
forms of the Shipley Personal Inventory. This 
last w^as developed largely under naval aus- 
pices, and had wide use in receiving ships, dis- 
ciplinary barracks, and precommissioning 
installations, as well as in recruit screening at 
training stations. 

Recruits who were obviously unfit or under 
strong suspicion of unfitness were referred 
from the screening line to a neuropsychiatric 

observation ward for a complete case work-up 
No recruit was separated from the naval serv 

ice without such careful, complete study 

important improvement over the less careful 
Selective Service procedure. The clinical psy- 
chologist played an important role on this ob- 
servation ward. His testing procedures, how- 
ever, resembled the standard individual testing 
techniques of civilian clinical practice, and the 
problems that arose were mostly the universal 
problems common to all clinical testing and not 
peculiar to the naval service. 

For testing intelligence, the complete 
Wechsler-Bellevue Scale for adult intelligence 
was used despite its time-consuming nature. 
This was supplemented by numerous special- 
ized techniques designed to meet the narrower 
problems of differentiating educational and 
cultural handicap, illiteracy, language difficulty, 
school achievement, and special ability. The 
testing armamentarium available in the Navy 
compared satisfactorily with standard clinical 

An important aspect of intelligence testing, 
here as on the screening line, came in the 
secondary diagnostic cues revealed by intelli- 
gence tests when administered to cases of func- 
tional mental disorder or the various organic 
brain conditions. Psychologists were probably 
called upon for more of such ''diagnostic" 
testing than they were for straight testing of 
the level of intelligence. 

Temperament or ''personality'' tests occupied 
a large part of the psychologist's time on the 
observation ward. The Rorschach ink blots. 
Thematic Apperception Test, and Minnesota 
Multiphasic w^ere among the more popular one> 
used. Because of the time factor — the Ror- 
schach might take an hour to administer— 
these tests were rarely available on the screen- 
ing line. 

In discussing the psychologist's evaluation oi 
patients on the observation ward, we should 
stress again that, both by official directive a^^ 
well as by precedent and practice, such evalua- 
tion w^as not limited to test scores but included 
case history materials and the results of - 
clinical interview. It was this general clinici^ 
function of the psychologist, based on his lonK 
experience in clinical interviewing, that y^' 



s;ulted in many essentially psychiatric duties 
being delegated to him as the war progressed 
and the shortage of psychiatric personnel be- 
came more severe. 
I There were many special testing duties as- 
signed to the clinical psychologist. Shortly after 
each recruit began his formal training, he was 
(riven a battery of paper-and-pencil tests de- 
signed to reveal any special job aptitudes. 
These included an intelligence test, the Navy 
General Classification Test, along with tests 
for aptitude and school achievement. The tests 
were administered by the Classification De- 
partment and formed the basis for assigning 
the recruit to a specific trade school. By direc- 
tive, any man receiving a score of less than 50 
on the General Classification Test (G.C.T.) was 
referred to the Psychiatric Unit for individual 
testing, to assure that mental deficiency was 
not involved. G. C. T. thus offered a further 
check on the screening examination in filter- 
ing out the feebleminded. 

Here again, the rough nature of group tests 
and the advisability of complementing them 
with individual testing were revealed. A low 
G.C.T. score may be obtained for many rea- 
sons, only one of which is mental deficiency. 
Had the low-scoring men been discharged 
solely upon the evidence of the group test 
scores, many militarily fit recruits would have 
been lost to the service. The Naval Training 
Station at Newport made a periodic survey of 
all such G.C.T. referrals during the years of 
1942 and 1943. One-third of the low-scoring 
recruits made a poor showing because of 
difficulties inherent in the testing situation 
itself — ^poor testing conditions, failure to under- 
stand the instructions, or inadequate motiva- 
tion. Another third represented marginal cases 
whose test performance was hindered by 
educational and cultural handicap (including 
illiteracy), but who were deemed of potential 
service to the Navy. The final third were 
adjudged unfit for service, but of these only 
one-half were cases of mental deficiency, the 
others representing various personality dis- 
orders. Thus, roughly only one-sixth of the men 
referred for low G.C.T. scores represented true 
cases of mental deficiency. 

At first, no illiterates were accepted for naval 

service, but as the war progressed and the 
manpower shortage became acute, they were 
accepted and assigned for special training in 
learning to read and write. Before being so 
assigned, all illiterate recruits were referred to 
the clinical psychologist for individual testing, 
to assure that the recruit had the necessary 
intellectual ability to benefit from special edu- 
cation. The problem of illiteracy was a serious 
one. Previous to the outbreak of the war, it 
accounted for only 2 percent of the inaptitude 
discharges at the Newport Training Station, 
but in 1942 this rose to 10 percent. After il- 
literacy ceased to be a reason for discharge and 
a special educational program was instituted, 
it was estimated that between 8 and 12 per- 
cent of all incoming recruits fell below the level 
of fifth grade reading ability that the Navy 
considered desirable. In some large training 
stations, such as Great Lakes, the clinical psy- 
chologists were given the overwhelming burden ~~ 
of individually examining from 200 to 300 re- 
cruits weekly for this reason alone. 

Individual examinations for intelligence 
were given in many other instances. Frequently 
they were necessary in selecting men for special 
duty, such as the submarine service. They 
were utilized in some cases where recruits were 
accepted with correctable defects, such as 
hernia. To be acceptable with an operable 
hernia, the recruit was supposed to have a men- 
tal age of at least 11 years, to merit the Navy's 
investment of time and medical attention neces- 
sary to render him fit for general duty. 

In addition to their evaluation of intelligence 
and temperament, clinical psychologists were 
called on for many other duties in connection 
with the screening program. We have already 
mentioned their research in connection with the 
development of psychological tests. Because of 
their research training, they were called on to 
cooperate in other research projects including 
the improvement of the psychiatric interview, 
the evaluation of other diagnostic procedures as 
electroencephalography, and the evaluation of 
various forms of therapy. In such investiga- 
tions, the psychologist's graduate training in 
experimental design, electronics, and statistical 
techniques was a vital and necessary comple- 
ment to the psychiatrist's clinical background. 



Here, as in other branches of the naval serv- 
ice, the psychologist assumed a large share of 
the research burden. 

Nor can we overlook his functions as a 
teacher. Many supplementary training courses 
v^ere developed by the Bureau